Document redmK2zw2kop5nN9g9JKDEVRG

INSTRUCTIONS: This medical report shoi ; completed by the attending physician immt` after first treatment for occupational disease. Mail same to the Bureau of Work* Compensation. Office addresses are listed on the averse side. This report should be used where claimant loses than one week from work because of occupational disease. STATE OF OHIO Bureau of Workers' Compensation claim n0. O.D. Attending Physician's Report of Occupational Disease 1. Name of disabled per in..... /t/l.......................*k..( 2. Address 1' /..... .J > Cj ) .... &.]....... ..........'2<S/*/-</' h ^...............24./.A.....___. i42.4Z 3. Date of first treatment by you ..9./2S/S&............ .......... Date of diagnosis___ 1Q./88.......... . .......... ................. 4. Give accurate description of nature and extent of disability ...HR't.U^.i...A^ios^COma of..theLiver^...Ascites Extent: Teiminal 5. Describe treatment ^Pa-tient; is on Diuretics for ascites , he is to be seen @ Tertiary Care Center which has expertise in liver transplant. 6. What is the diagnosis?......Angiosarcoma ofthe Liver, Ascites........ .............. ........................ 7. What in your opinion is the cause of the disease? .... Caiisa..CQULd..p.OSSiJaly...ho...frcni_ exposure to____ chemicals where he was employed. 8. Give your best opinion as to the date claimant will be able to return to work _.._5?$_ired____________ ______ 9. Has this occupational disease resulted in a permanent disability? .....y......................... .................................. . If so, what?......Datient.-ls-teminally -ill^........... ..................................................................................... 10. Mention any previous injury or condition contributing to the claimant's present disability ................................ 11. Give name and address of any other physician who acted as: (a) Assistant ..Dr....HarlenJVaid 125 S. Chestnut ST d:f.f.er9.ni...OtL.rAP4Z Primary Physician .....(b) Consultant (c) Anaesthetist 12. If services were rendered by hospital, special nurse, X-ray or ambulance, give name and address: HH,,oosspp.iittaa.ll St. Vincent 232 17.'25th Health Center IBTC'ErTe "PA 16544 X-ray Special Nurse Ambulance ... 13. Name and address of employer: General Tire,, anc1 Akron, Ohio (3on?)ar,Z Graduate of ... Bombay...University. Bombay , India Year ..............1966_______ ___ ___ License No______ iDD0_1034 VE 0-D-4a Street Address City or Town..... _..2T_1....?A.....A!?2 Phone 814-45272767 .... Fed. 10##..225-1206468 RCiV3 JAN 3 1389 CORKER'S COMPENSATION OEF. GENC 002866