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RESET Assessment Report
Claim Number (If known)
Please complete in full using black ink.
Incomplete or illegible reports will not be paid. START HERE >
Patient Information
Last Name First Name Initials Social Insurance No.

Address City Date of dd mmm yyyy

Birth
Province Postal Code Telephone No. Sex
( ) M F

Employer Information
Employer Name

Address City Province Postal Code

Telephone No FAX No. Date of dd mmm yyyy

( ) ( ) Accident

Date of Initial dd mmm yyyy Name of Referring Health Professional

1 Assessment
Patient's History of Injury

Physical Findings

Working Diagnosis
4

Is Treatment Required? yes no If yes, describe the goals for treatment and approximate duration/frequency of treatment

Treatment Program Proposed Can the patient work while participating in treatment? yes no

Are there any physical restrictions that should be observed?. yes no If yes, what are they?

Complete recovery expected? yes no If yes, approximately when?

8
Describe any factors (including pre-existing or underlying conditions) which may delay recovery.
9

Physiotherapist's Name Health No. Version

Code
Address City/Town WSIB Provider Billing No.

Province Postal Code Area Code Telephone No. Your Own Invoice No. Service mmm
Date yyyy Fee Code
dd
( ) P 9 7 0
Physiotherapist's Signature Date
Please print form, then sign & date before returning to the WSIB
0856C (03/00)