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BC TRANSIT - VICTORIA
TRANSLINK SECURITY MANAGEMENT LTD.

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ATTENDING PHYSICIAN’S STATEMENT

1. PATIENT'S NAME: DATE OF BIRTH:

YEAR MONTH DAY
2. CURRENT HEIGHT: CURRENT WEIGHT: EMPLOYEE NUMBER:

3. DIAGNOSIS (INCLUDING ANY COMPLICATIONS)

PRIMARY

SECONDARY

SUBJECTIVE SYMPTOMS:

OBJECTIVE SIGNS (INCLUDING RESULTS OF CURRENT X-RAYS, BLOOD PRESSURE, LABORATORY DATA AND ANY RELEVANT CLINICAL
FINDINGS):

4, HOSPITALIZATION, IF APPLICABLE FOR THIS ILLNESS OR INJURY:

DATE OF IN-PATIENT ADMISSION: DATE OF DISCHARGE:
YEAR MONTH DAY YEAR MONTH DAY

DATE OF OUT-PATIENT TREATMENT:
YEAR MONTH DAY

NAME OF HOSPITAL:

REGISTERED BED PATIENT?
FROM: TO:
YEAR MONTH DAY YEAR MONTH DAY
DAY SURGICAL PATIENT
YEAR MONTH DAY
KIDNEY DIALYSIS
FROM: TO:
YEAR MONTH DAY YEAR MONTH DAY
CHEMOTHERAPY
FROM: TO: ———————
YEAR MONTH DAY YEAR MONTH DAY
RADIATION THERAPY
FROM: TO:
YEAR MONTH DAY YEAR MONTH DAY
EMERGENCY WARD (0.P.)
YEAR MONTH DAY
5. SURGERY
SURGICAL PROCEDURE PERFORMED:
DATE OF SURGERY: NAME OF SURGEON:
6. HISTORY
DATE SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED.
YEAR MONTH DAY
HAS PATIENT EVER HAD THE SAME OR SIMILAR CONDITION? YES NO

IF YES, PLEASE SPECIFY DIAGNOSIS AND DATES.

7. TREATMENT

WHAT IS THE CURRENT TREATMENT REGIMEN? (DRUG DOSAGE, PHYSIO, OTHER AND PROGRESS)

PLEASE INDICATE ALL DATES OF VISITS FOR THE CURRENT CONDITION:

Month Year} 1} 2} 3] 4/5 |6 | 7/8 {9 |10 |11 }12 | 13] 14) 15) 16/17 | 18)19 | 20} 21| 22] 23] 24 | 25} 26 | 27 | 28 | 29/30 | 31

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