Evolve Standard Questions (Check all that apply)
What is the diagnosis?
Use - Is the diagnosis an aggravation of a pre-existing condition or solely the direct result of this accident?
Use - If the diagnosis is an aggravation of a pre-existing condition, has the Claimant recovered to his/her pre-accident status? If not, please estimate the time such recovery might take.
Use - Please outline any objective organic pathology to substantiate subjective complaints.
Use - What is the claimant’s prognosis?
Use - Please identify the recovery made to date.
Use - Please comment on any other information pertinent to this case.
Use - Do you feel that you have had adequate information provided to you to accurately conclude your assessment opinion?
Use - Q9. Treatment Plan (OCF-18) Review
Are the goods and services, contemplated in the (OCF-18) in question, reasonable and necessary as a direct result of injuries sustained in the accident?
Use - Please provide a detailed rationale and supporting evidence with your response
Does the claimant’s injury meet the definition of a Minor Injury as defined by the SABS?
Use - Subject to the above, does the claimant’s treatment fall within the Minor Injury Guideline (MIG)?
Use - Is there a documented pre-existing condition, and if so, does the documented pre-existing condition prevent the claimant from achieving maximal recovery from the accident related impairment if limited to the medical and rehabilitation limits of $3500.00?
Use - If yes to the above, please provide your recommendations for treatment or assistance to manage these needs.
Does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident that causes a substantial inability to engage in the essential tasks of their pre-accident employment?
Does the claimant currently suffer from an impairment as a direct result of injuries sustained in the accident that causes a complete inability to engage in employment for which they are reasonable suited by education, training or experience?
Does the claimant suffer from a complete inability to carry on a normal life as a direct result of injuries sustained in the accident?
Does the claimant suffer a substantial inability to engage in the care-giving activities in which he or she engaged at the time of the accident?
Use - If yes, do you have any recommendations to assist in facilitating a return to care-giving activities?
Does the claimant suffer from an impairment as a direct result of injuries sustained in the accident that results in the need for attendant care assistants? Please complete a form 1 to detail the level of assistance required in accordance with the SABS regulations.
Does the claimant suffer a substantial ability to complete his/her pre MVA housekeeping and home maintenance activities?
Use - Please advise us of any complications or extenuating circumstances which may be prolonging the disability, thereby preventing a return housekeeping and home maintenance activities.
Does the claimant currently suffer from a catastrophic impairment in accordance with the definition detailed in the (OCF-19) in question?
Use - Did the claimant sustain a catastrophic impairment, as defined by the SABS, as a direct result of the accident?