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Wage Impact Estimate Referral Form

Personal Data
Client's Name (Optional)
Your Case File Number
Gender		Male Female
Client's Date of Birth
State of Residence
County of Residence
Education
Highest Grade Completed
Highest Degree Completed
Subject (Field of Study)
Special Training/Skills
Work History
Job Title	DOT Code (if known)	Dates (years only)	Wage (per hr)	Union (yes/no)	Brief Job Description

Medical Data/Physical Limitations (as taken from medical reports)
1. Please list current diagnoses which resulted from injury (as reflected in medical reports).
2. What is the date of physician report from which physical limitations information below is taken?
3. If yes, please describe limitations below:
LIMITATION (Based on 8 hour work day)
Strength (lifting/carrying/pushing/pulling)
Sitting
Standing
Walking
Need for alternate sitting/standing/walking?		Yes No
4. Please list any other functional limitations resultant from injury as described in medical reports.
5. Please list any other functional limitations from pre-existing conditions.