Document QJ7bja6zKpkdDKyEXymo9BgY7

FILE NAME Talc TALC DATE 1989 DOC TALC043 DOCUMENT DESCRIPTION Worker's Comp Claim ... DU... G | ... IGF tha: ' 4 .HECK INITIAL INITIA[L7 PROGRESS |. FINAL . PLEASEPLEASE | WCB WCB CASE NO Known CARCRAIRERIER KCARnRIERoCwASnE NO. ry DATE OF INJURY AND TIME PLEASE PLEASE JURED ( ERSON PRINT | pL William First Name e Douglas Middle Douglas late 1970's Bowman AGE Last Name 63 PRINTEMPLOYER ... St. Joes Resource Co OR INSURANCE OR CARRIER INSURANCE Traw SUPERVISING Traw SUPERVISNG PHYSICIAN Traw if any Guardian Claims Claims ~ RY , . . < CHECK TYPE OF DOCTOR PHYSICIAN [ PODIATRIST | CHIROPRACTO ADDRESSOCCUROCR URED ED he INJURED INJURED PERSON'S PERSON'S Balmat NY 136423 ADDRESSADDRESS Include Apt No. Gouverneur NY 136423 Box 342 721-07-4499 TELEPHONETELEPHONE NO 287-0432 Balmat NY m OCCUPATIONAL Resource TYHESIS INFyOReMAaTrIOsN Patient tegning insert FlerAeLL RITEeMSfor OCCUPATIONAL Co. RAENPDORGTIVE cShOeURsCtE INFORMATION COMPLETE exertion {_} cough * . If treatment was rendered under the Volunteer Firefighters Benefit Law show 1. HAVE YOU FILED A as EMPLOYER the ilable political subdivision and enter X here FORTH A HISTORY PREVIOUS OF SETTING IF YES ENTER DATE } THE INJURY on : = OF SUCH REPORT BELOW IF NO COMPLETE A. INJURY OCCURRED OCCURRED AND ITEMS 3-10 BELOW ; BELOW OCCUPATIONAL HISTORY AND IF CLAIM IS FOR OCCUPATIONAL DISEASE INCLUDE St. Joes years for 41 yrs About 10-12 , Ce] Refor of breath on wheezing pain and These symptoms have progressed and <2O+4 DOCTOR B. WAS PATIENT PREVIOUSLY UNDER THE CARE OF ANOTHER NO ADDRESS 5S - FOR THIS INJURY IF YES ENTER HER NAME AND IN ITEM 10 AND REASON FOR TRANSFER C. WERE RAYS TAKEN _. 2. IF THERE IS ANY HISTORY OR EVIDENCE OF EXISTING INJURY DISEASE OR PHYSICAL IMPAIRMENT DESCRIBE SPECIFICALLY ~s None xte . eS | 3. DESCRIBE NATURE AND EXTENT OF KNOWN OR REPORTED CHANGE OF CONDITION SINCE LAST REPORT The INJURY OR DISEASE WHEN EXAMINED patient has AND IF APPLICABLE ANY asbestosis and silicosis He has pneumoconiosis which is most likely possibly restrictive lung disease as a result of the pneumoconiosis His airways have been affected by his workplace exposures also and he -nozar o en most has likely bronchospastic 4. component to his disease as wetk DATE OF EXAMINATION DATE FIRST ON WHICH THIS REPORT TREATMENT YOUR WHEN IS BASED 2/23/89 , { TREATMENT 2/23/89 ARE YOU CONTINUING IF YES ITREATMENT BE PATIENT pru 8. DESCRIBE TREATMENT , YES NAME AND RENDERED AND PLANNED FUTURE TREATMENT eval- LOCATION OF HOSPITAL AND DATES OF HOSPITALIZATION . IF PATIENT WAS HOSPITALIZED SO STATE AND GIVE The patients status was uated A future treatment should include pulmonary toxic to the avoidance of dusts and irritants that may be respiratory tract and agressive treatment of any pulmonary infections 6. RESULT IN PERMANENT RESTRICTION RESTRICTION INJURY RESTRICTION TOTAL OR PARTIAL LOSOS R FUNCTION OF A PART OR MEMBER PERMA [ses] NENT FACIAL HEAD OR NECK DISFIGUREMENT IF YES DESCRIBE The lung disease is perpermmanaentnent and irreversible irreversible ireversible 7. PATIENT LIMITED WORK REGULAR WORK WORKING = YES IF YES ON WHAT DATE DID PATIENT IF ON - ee | RESUME OF ANY KIND RESUME ~~ PATIENT | DISABLED '' IF YES CHECK ONE [ PARTIAL DISABILITY DISABLT NOT DATE [vss | NO | DATE i | TOTAL CAUSAL 8 WAS THE OCCURRENCE DESCRIBED ABOVE OR IN YOUR L ELATION MATION THE COMPETENT PRODUCING CAUSE OF THE PREVIOUS REPORT WHICH GAVE THIS INJURY INFOR NO | . AND DISABILITY IF ANY SUSTAINED DISABILITY IEHABILI TATION rn>Eima 4 9. s ANY FACTORS DELAYING RECOVERY IF YES DESCRIBE YES O b VOCATIONAL REHABIREHABLILITAITIONTVOACTATIIOONANL [ng] IF YES GIVE REFERRAL DETAILS RECEIVED RECEIVED RECEIVED APR2626 ENTER HERE ADDITIONAL PERTINENT INFORMATION WORK LIMITATIONS IF ANY ETC. 226 s6nea abbestos riskkfor lung Because of his exposure the patient is at increased cancer and mesothelioma be examined Heshould annually of If your testimony should be necessary in this case please indicate the days of the week and timde ay AM or PM SERVICES Fridays most convenient to you for this purpose Mondays 4/25/89 with these possibilities in mind ' AUTHORIZATION FOR SPECIAL p.m. REQUIRED SEE ITEMS AND . Dated Typed or Printed Name of Attending Doctor Address 4/25/89 550 Harrison Harrison CES 20gutte NCB Rating Code Michael H. Lax M.D. WCB Authorization No. | Telephone No. . 473-5422 Harrison Written Signature of 300 300 PM - 473-5422 Attending Doctor 176488 Facsimile BR BBR --...-- Facsimile Not Accepted ) CHIROPRACTOR CHIROPRACTOR R --...-- FILING THIS REPORT CERTIFIES THAT THE INJURY DESCRIBED CONSISTS SOLELY OF A CONDI- LAWFULLY BE TREATED AS DEFINED IN TREATED THE INJURED PERSON TO CONSULT A PHYSICIAN OF HER CHOICE THE EDUCATION LAW AND WHERE IT DOES NOT HAS ADVISED Combined Combined / 48 48 5-88 SEE REVERSE SIDE FOR IMPORTANT INSTRUCTIONS CARRIER'S COPY