STATE OFCALIFORNIA

l{ithin

DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS

your initial examination, for every occupational injury or illness, send two copies of this rcport to the employer's workersr compensation
insurance carrier or the insured employer. Failure to file a timely doctorrs report may result in assessment of a civil penalty. In the case of diagnosed or
suspected pesticide poisoning, send a copy of the report to Division of Labor Statistics and Research, P.O. Box 420,603, San Francisco, CA 94142-0603, and
notify your local health officer bv telephone within 24 hours.
PI,EASE DO NOT
1' rNsuRER NAME AND ADD*tt
5 days of

Bo*"a \he

2.EMPLOYERNAME
3. Address

\\ocs,

\tsoot Nnirnc"\ Dr

Ncrse,\ean \tue

No. and Street

\(,oo\

9r.

NnitrroN

.:t

USETHIS
COI I IMN

-(

CeNo,

cngq3}-\GtQ

Fo.finllilte,'

Ao

(I

IndNtry

L\<rGt

{on$h Care

4. Nature of business (e.g., food manufacturing, building construction, retailer of women's w'v',wr''
clothes.) 6-

Coutrty

Fcrcrnirq cr.cd Ccrts\c,$ic;\r

5.

PATIENT NAME (first name, middle initial,last name)

Bor.er

8. Address:

Occupation (Specificjob

10.

2. Injured at:

title)

\
-tso.CTne( o.\i'q\

No. and Street

\tcCIt AsiwtP<

13. Date and hour

Mo.

of injury

or onset of illness
15. Date and hour

Yr

Day

\Jorevnbc,

\tr

Mo. Dav

offint

(A

t",,arlui

hq,

7. Date

VMul" ft Female

Citv

No. and Street

l*CC\

6. Sex

T. W,

zip

Mo.

Yr.

Dav

aI

Apc\\

Age

\\

lcpt

Haard

9. Telephone number

tr

(!Qt,)rr'6-l:is:l

Gx
\**.f'K.,

c\

35\-

Un^,\ea SArr\

qA -2;13L

Hospltaliation

\tlo

Arnerisc..

14. Dale last

worked

Mo. Dav

AloverWt

o.,,

Hour

Dl*se

1. Social Security Number

County

Groo

\5

Yr.

of

Birth

USH

nigtrts

Occupation

Yr.

r<l [or*

qtr^efl(cts{rrrt{it$

16. Have you (or your office) previously

treated
Yes

Retum D.te/Code

,.n,. \: CC) p.m.

patient? I
lr,lovernber \X, Aor5
fNo
\03111
Patient please complete this portion, if able to do so. Otherwise, doctor please complete immediately, inability or failure of a patient to complete this portion shall

-1'*'

examination or treatment

not affect his/her rights to rvorkers' compensation under the Califomia Labor Code.
17. DESCRIBE HOW TIIE ACCIDENT OR EXPOSURE HAPPENED. (Give specific object, machinery or chemical. Use reverse side

required.)

\r

\..

rr

SUBJECTM COMPLAINTS

18.

(Describe

fully.

Use reverse side

\!fqq \s/e c[r\ o.c\1\T\g Fc$r\, o.{ts

hn$sr.S \\cr.\ f ysJ Prev\o$A\ 3p\\\ 6\3 S\i
fhv

if more space is required.)

t brCo{\e.
:/ es?ec\q\\\ o,Q\ec \onq t.rnV

I qsd S\crVb'rrB r,.Ner.

cheS\ Gt.d

OBJECTM HNDINGS

19.

if more space is

rs"
befir kviw5 $ou\ \\o,
go! -,e11T13 )R:\\$g
sk$es \T"' eqi Ccx\, T. hodqrcL$nd.
"o U\e\ t I g\dderr,
CJ^ceJ\F3Vr'{.1,
} ac/i'\c}h\ PT}X fth)
co\fovefd cm.\o \\',{
qQ_mt cq({ Sove R.eng \cund ff o.\d \eer\ tre \o o"'\stftry bmn.

..

(Use reverse side

f^Y
T

if more space is requircd.)

A. Physical examination

) \r

v\Srb\r 3$S\,fq

- \\fcr\rSVr\
-' \s53\
J',

i..i.s,-\,

B. X-ray and laboratory results (State

if non or pendins.)

buJ gc,ylX

,\eezinS \n c\eS\/

pCI

pe\s iSg

20.DIAGNosIS(ifoccupationalillnessspecifyetiologicagentanddurationofexpoJure.;ct,"

ICD-9 Code

21.Areyourfindingsanddiagnosisconsistentwithpatient'sac"ountofi",priiieEplai,.
22. Is therc any other current condition that
23.

will impede or delay patient's recovery?

.,

\ g

-S o

Yes VNo If "yes", please explain.

TREATMENT RENDERED (Use reverse side if more space is rcquircd.)

pc"\ies'l

\S\qn\r

phls\cc-r\ (korF-\m*,icin,

ches\

>?ro"\r prescc\bed

o(\83$

24. If further treatment required, specify treatment plan/estimated duration.

,\
et6, a c\c\ \o\0 \tlcka isio
i$ aosdi\ic1r
location
Date
Mo. Dav yr.
\Ji\rinqdo.o NptVr\r,\ tgGog Hcggr\il Dc.\li\irgtonlCA t{t?q\ admiued Nc,(nb<r Q., acrs
.(

25.

lt hosprtalized

i<,:

Doctor's

signrt

Sucge(\

as inpatient, give hospiral name and

26. WORK STATUS -- Is patient able to perform usual

rf "no", date when patient can return

?r'{rh A,

#i*i*

til]ba

DoctorName andDegree(ple"r"*yp"l

5t,\\c* BoVgt, \0,D

ou** 3qOqg-R''*o"..eY

msNumuer

3qG Ist{

nl

inl

u orke rs' cornpeusltion bcncfits

qst } o t

{93q)\b\t

TelephoneNumber('Jr\"'

de

fr

ot c,.ri't.\t$ r n<l \it\in3 o,lcj

qO

t{- qq D5

1992

Ibr thc purpoic (r' ()btaining or

\oe-aicdi<

{Uro rrrq\\S

Specify restrictioos No qcr\ogvrg

cA License Numu",

Qqir\

Estimated stav

;ork? l Yes--ffi;

ff#,H;,;*_

\(.os\- q\a

ol ltal mcnts is suiltr of a f e lcxr\

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