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Physiotherapy Progress Report - ICBC

C L 4 8 9 F (1120 2 2) Physiotherapy Progress Report Page 1 of 4 Physiotherapy Progress Report If applicable, please select the Lock button before submitting the form. Please note: once the Lock button has been selected, the form will no longer be INFORMATIONCLAIM NUMBERDATE OF ACCIDENT (dd/mmm/yyyy)DATE OF Report (dd/mmm/yyyy)VENDOR NUMBERINVOICE/REFERENCE NUMBERPAYEE NAMEPAYEE ADDRESS PAYEE ADDRESSCLIENT INFORMATIONFIRST NAMELAST NAMEDATE OF BIRTH (dd/mmm/yyyy)PERSONAL HEALTH NUMBER (PHN)PRACTITIONER INFORMATIONFIRST NAMELAST NAMEPRACTITIONER NUMBERA ssessmentDATE OF ASSESSMENT (dd/mmm/yyyy) NUMBER OF TREATMENT SESSIONS TO DATEDATE OF PREVIOUS ASSESSMENT (dd/mmm/yyyy) DATE OF FIRST VISIT (dd/mmm/yyyy)RELEVANT PRE-ACCIDENT HISTORYARE YOU AWARE OF ANY PRIOR INJURIES OR MEDICAL CONDITIONS AT THE TIME OF THIS ACCIDENT?

CL489F (052021) Physiotherapy Progress Report Page 5 of 5 Return to ADLs 4. HAS THE CLIENT RETURNED TO ADLs? l es Y l No IF NO, SELECT ESTIMATED RETURN TO ADLs: Communication Request 5. DO YOU WISH TO HAVE A PHONE CONSULT WITH THE CLAIM FILE HANDLER? l es Y l No 6.

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