FIRST MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD) COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 (Act number 130 of 1993) [Section 6A(b) – Commissioner's rules, forms and particulars – Annexure 25] DETAILS OF INJURED EMPLOYEE Surname: Initials: Date of birth: Gender: Occupation: RMA Claim No: Industry No: Date of Accident: / / Employer: Tel (H): Tel (W): CELL: DETAILS OF INJURY Date symptoms first Date of first Date of specific started consultation: diagnosis: Specific diagnosis of this upper limb disorder: The symptoms the employee experiences (tick the appropriate box/es): Burning sensation Fatigability Loss of grip strength Loss of normal sensation Muscle weakness Pain Paraesthesia (tingling) Sensation of cold Swelling Stiffness and cramps Describe: The clinical signs found on examination (tick the appropriate box/es): Crepitus (cracking sound in subcutaneous tissue) Muscle spasm Muscle weakness Reduction of range movement Swelling Tender trigger points in muscles Tenderness Describe: Is the employee left or right Right Left Male Female years 7. Sex:* Age: handed?* Body mass 8. Height of employee: cm Weight of employee: kg index: 9. Which special medical investigation(s) and/or job analysis or ergonomic assessments were done to prove the diagnosis, and/or what other potential causes of the above-mentioned upper limb disorder have been investigated or eliminated? (where applicable, please attach these reports)
FIRST MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD) COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 (Act number 130 of 1993) [Section 6A(b) – Commissioner's rules, forms and particulars – Annexure 25] DETAILS OF INJURED EMPLOYEE Surname: Initials: Date of birth: Gender: Occupation: RMA Claim No: Industry No: Date of Accident: / / Employer: Tel (H): Tel (W): CELL: DETAILS OF INJURY Date symptoms first started Date of first consultation: Date of specific diagnosis: Specific diagnosis of this upper limb disorder: The symptoms the employee experiences (tick the appropriate box/es): Burning sensation Fatigability Loss of grip strength Loss of normal sensation Muscle weakness Pain Paraesthesia (tingling) Sensation of cold Swelling Stiffness and cramps Describe: The clinical signs found on examination (tick the appropriate box/es): Crepitus (cracking sound in subcutaneous tissue) Muscle spasm Muscle weakness Reduction of range movement Swelling Tender trigger points in muscles Tenderness Describe: 7. Is the employee left or right handed?* Right Left Sex:* Male Female Age: years 8. Height of employee: cm Weight of employee: kg Body mass index: 9. Which special medical investigation(s) and/or job analysis or ergonomic assessments were done to prove the diagnosis, and/or what other potential causes of the above-mentioned upper limb disorder have been investigated or eliminated? (where applicable, please attach these reports)
WRULD-First-Medical-Report-in-Respect-of-a-Work-Related-Upper-Limb-Disorder.docx