PATIENT’S NAME : SURNAME, FIRST NAME

DATE OF BIRTH : mm/dd/yyyy

GENDER :
CLAIM # :
WCAB # :
DATE OF INJURY : mm/dd/yyyy
EMPLOYER : TRAKTIR GROUP, INC.
PLACE OF EVALUATION :

RECORDS SUMMARY

Enclosed were ___ pages of records and all of these materials were reviewed to
ensure that no relevant information was overlooked. Records included ___, ___.

NON-MEDICAL RECORDS

MEDICAL RECORDS

THERAPY REPORTS

DIAGNOSTIC STUDIES

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 Patient’s Name: SURNAME, FIRST NAME
Date of Birth: mm/dd/yyyy

Applicant’s Hypertensive/
Date of Applicant’s HgA1C
Provider Blood DM Weight
Encounter Heart Rate values
Pressure Medications
120/80
Ming mmHg
November 140
Luong, (sitting left); 81 bpm Insulin 70/30 11.1%
8, 2021 pounds
R.N.P. 120/90
mmHg

End of Summary.

**use this table only when the doctor is IM/PULMO**

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