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Figure 161b. Upper Extremity Impairment Evaluation Record Part 2 (Wrist, Elbow, and Shoulder) Name:Age:Claim No:Sex:Date of Injury:Employer: Abnormal MotionOther DisordersRecord motion or ankyloses
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- Begin by entering the name of the patient in the designated space.
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- Next, input the date of birth of the patient.
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- Provide the patient's address including street, city, state, and ZIP code.
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- Indicate the patient's gender, whether male or female.
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- Enter the patient's phone number.
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- Fill in the patient's social security number.
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- Specify the patient's marital status, such as single, married, divorced, or widowed.
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- If applicable, provide the name of the patient's employer.
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- Indicate the patient's occupation.
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- Write down the name of the referring physician, if any.
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- Input the date of the patient's first visit.
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- Lastly, ensure all information is accurate and legible before submitting the form.
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Draft AMA Figure 16-1b is required by healthcare providers and medical practitioners. It serves as a standardized form for gathering essential patient information, ensuring consistency and completeness in medical records. It may be used in various healthcare settings such as hospitals, clinics, and private practices.
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Draft ama figure 16-1b is a form used for reporting certain financial information.
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