Medical Report Occupational Disease - Kentucky 2026

1. Click ‘Get Form’ to open the Medical Report Occupational Disease - Kentucky in the editor.
2. Begin by filling out the Plaintiff Information section. Enter the plaintiff’s name, address, Social Security number, date of birth, height in centimeters, job title and employer, date of examination(s), and purpose of examination.
3. In the Plaintiff History section, provide a detailed account of any complaints related to occupational disease. If applicable, include smoking history for lung or heart-related diseases.
4. Complete the Employment History section by reviewing and listing pertinent employment details from the attached Form 104.
5. Document prior and current treatment in the Treatment section. Include any hospitalizations related to the complaints.
6. Fill out the Physical Examination results with objective medical findings relevant to the occupational disease.
7. In Diagnostic Testing, check applicable tests reviewed and indicate whether they were personally reviewed.
8. Provide a Diagnosis and Causation summary based on your findings. Answer questions regarding causal relationships between work environment factors and health conditions.
9. Assess Impairment using AMA Guides and specify any prior active impairments if applicable.
10. Detail Restrictions based on physical requirements of work performed at injury time and indicate if the plaintiff can return to that work.
11. Finally, certify all information provided is correct in the Certification section, including your qualifications as a physician.

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