Document xjpkqJVgewNbm4JX1eqRNdEXG
FILE NAM E: Talc (TALC) DATE: 1989 DOC#: TALC043 DOCUM ENT DESCRIPTION: W orker's Comp Claim
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C A R R IE R .C A SE Ilf Knswnl
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NO.
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R S O N (F lu t Nm)
Douglas
(M id d le Initial)
employer*
*v:-
St. Joes Resource Co
IN SU RA N C E
C A R R IE R Guardian Clime .
S U P E R V IS IN G
PH Y SIC IA N Ilf any)
X.
vi
CHeCK TYPe O P OOCTOH:
DC P H Y S IC IA N 1 1 [P O O IA T R IS T I 1 p H IR O P R A C T O r
DATE OF INJU R Y
AN D TIM e
_ ^ ".^ T O ^ N JU J^ U W W E Q
late 1970 8
Balaat, HT
Bowman
A G S ADDRESS (Ineiud t Apt. No. , -
IH it N s m ! 63 Gouverneur. NY 1 3 2 3 B o x 3*z
7 2 1 -0 7 -4 4 9 9
TELEPHONE NO. 2 8 7 -0 & 3 ?
_ Balaat, NY
' *
m r t ^ o i i . cough, e h u e pln. d haul,,.;
.
.
____________j f i 8 r
These symptoms have progressed anc
* ' " V * * "* "~*~nn.rn ril stimili,.
C. W ER E X-RAYS TAKEN?
*s?
NO
IF T H E R E IS A N Y H IS T O R Y O R E V ID EN C E O P P R E - E X IS T IN G IN JU R Y d is c . . . - -
------- L _ --- :_____________________ --
*
IN JU H Y . D ISEA SE OR P H Y S IC A L IM PA IR M EN T , D ESC RIBE SPEC IFIC A LLY-
None
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C H A N G E O P C O N O m O N ^ I N ^ L A S T R E P O R T ? l ^ e ^ a t Y a n t ^ h a 2 Y>^.D IS E A S E j W H N E X A M IN E D A N D IP A P P L IC A B L E . A N Y
asbeatoais and poftibly elUcoels.
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pneumoconiosis. M m airways have been affected
disease as a result of the
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axrected by his workplace exposures also and he Haa
aost likely has a-*ronchoapasclc component to his die *<, ,eU.
4* *T6{S) O P e x a m i n a t i o n
, D ATE O P Y O U R FIR ST
i *S BA Sg Q H T H IS r e p o r t 2/23/89
T R EA T M EN T
.A P B VO U C O N T IN U IN G IF " Y E S " W HEN W IL L
T R EA TM EN T ?
PA T IEN T BE SEEN
*
, A G A IN ?
coxxc t the respiratory tract and agressive treatment of any pulmonary Infections.
J Tt LOH ' AESYT R ? r V i n U T X - ? S U L T ,N P E R M A N E N T
FU N rT n li n e '
P A R T IA L LOSS OP
N E M T ^ d n i , A * T O B M E M B E R , OR FERMA-N E N T f a c i a l . H E A D o r N E C K O IS P IO U R E M E N T ? __________
IP " Y E S " D E S C R IB E ---------------------------------------" ---------
NO The lung disease Is permanent and Irreversible
' W ORKING? YES
CauMk lUkTIOM
Li - !X ! f '1 P XXHA TJ1 ;X IJ ? ,_ E ' P A T IE N T
I RESUM E LIM IT ED WORK OF ANY KIND
RESUM E
D A T E:
DATE:
REGULAR
WORK
IS PA T IEN T O ISA BLED ?
Yg5
NO
1 IF "Y E S " CHECK ONE
I
PA R T IA L D ISA BILIT Y
[ |X TOTAL DISABILITY
IC" NO
9- 1) A N Y F A C T O R S O E L A Y I N G R E C O V E R Y ?
ITlHATAtOIttltl
IP Y ES'? O E S C R IB E
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a n d /o r V o c a t i o n a l
.n=E i l , BJ U ' T A T I0 N I N D I C A T E D ? IP YES- G IV E R E F E R R A L D E T A IL S
YES
DO
YES 1
REC EIVED APR
OlUslQ& Written Signatur of
A<Fttecnadlminilga ONoocttAore e a o ta d )
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ED UCATIO N LA W AND. W H E R E IT O O ES NOT. HAS A D VISED
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SCC R S V S R S C 10 F O R IM PO R T A N T IN ST R U C T IO N S
C A R R IR T S C O P Y