Albert R. Swafford, M.D.
Board Certified Orthopaedic Surgeon
Qualified Medical Evaluator
Mailing Address:
1680 Plum Lane
Redlands California 92374
909-335-2323
DATE
****
****
***
RE:
DATE OF EVALUATION:
EMPLOYER
DATE OF INJURY:
CLAIM NO:
PANEL NO:
ORTHOPEDIC PANEL QUALIFIED MEDICAL EVALUATION
This is an INITIAL ORTHOPEDIC PANEL QUALIFIED MEDICAL EVALUATION,
performed in the County ************ on ************* ***.
BILLING: ML-20*-9* is billed, noting ** pages for review which included a declaration
and attestation. These records have been reviewed by me and this statement is made under
penalty of perjury. Face to face time was 40 minutes today.
OR – If exceeds 200 pages of records
BILLING: ML-******* + MLPRR is billed, noting ****** pages for review. These records
have been reviewed by me and this statement is made under penalty of perjury. A summary
of the records was prepared by my staff. Face to face time was ***** minutes today.
RE: *, *
DOS:
Page 2
Thank you for the opportunity to evaluate **** on ***, *** in my office at ***
The history and physical examination is not intended to be construed as a general or
complete medical evaluation. It is intended for medical legal purposes only and
focuses on those areas in question. No treatment relationship is established or
implied.
This medical-legal evaluation is based only on the current information and records
submitted. It is solely the treating physician’s responsibility to determine their
patient’s differential diagnoses and subsequent needs for medical treatment. This
would be inclusive of all psychiatric conditions, vascular diseases, neuromuscular
disorders, central nervous system disorders, auto-immune diseases, internal medicine
disorders and all tumors, benign or malignant, even if they are undiagnosed or
currently occult.
Introduction and purpose of evaluation
1. Do you believe the applicant has experienced a valid injury during his
employment with ****? lf so, would you please provide the basis for your
opinion in that regard.
2. Do you believe that the applicant has suffered temporary disability because of
the injury? lf so, would you please provide your opinion regarding the
beginning and ending dates of such disability?
3. Do you believe that the applicant will require future medical treatment because
of such injury? lf so, would you please provide you opinion regarding the
nature and extent of the anticipated future medical treatment?
4. This claim falls under the AMA Guides to the Evaluation of lmpairment [Fifth
Edition]. Therefore, would you please provide your opinion of the applicant's
impairment under the AMA Guides?
HISTORY OF INJURY BY PATIENT
Insert History.
PRESENT COMPLAINTS/ACTIVITIES OF DAILY LIVING
RE: *, *
DOS:
Page 3
Activities of Daily Living -
Categories
Self-care & personal
hygiene:
Urinating
Defecating
Brushing Teeth
Combing Hair
Bathing
Dressing Oneself
Eating
Communication:
Writing
Typing
Seeing
Hearing
Speaking
Physical Activity
Standing
Sitting
Reclining
Walking
o Assistive
Device-no
o Elevations
o Grades
o Long Distances
Climbing Stairs
Sensory Function:
Hearing
Seeing
Tactile Feeling
Tasting
Smelling
RE: *, *
DOS:
Page 4
Non-Specialized Hand
Activity:
Grasping
Lifting child
Opening a
window
Travel:
Riding
Flying
Sexual Function:
Sleep:
Restful Sleep
OCCUPATIONAL HISTORY
THE EXAMINEE BEGAN WORKNG FOR -
EMPLOYERS:
PAST MEDICAL HISTORY
PREVIOUS SYMPTOMS/
TREATMENT TO AFFECTED AREAS: None.
MEDICAL ILLNESSES: None.
SURGERIES: None.
DRUG ALLERGIES: The examinee has no known drug allergies.
CURRENT MEDICATIONS: None.
RE: *, *
DOS:
Page 5
FAMILY HISTORY: Family history is remarkable for prediabetes on the maternal
side.
REVIEW OF SYSTEMS:
ENT: No hearing loss or difficulty swallowing.
Endocrine: No known thyroid disease or heat/cold intolerance.
Skin: No new rashes or skin lesions.
Respiratory: No wheezing or asthma problems.
Cardiovascular: No chest pains or palpitations.
GI: No abdominal pain, nausea, gastritis, diarrhea, constipation, or vomiting.
Neurological: No fainting spells, loss of consciousness, dizziness, blackouts,
memory loss, or seizures.
SOCIAL HISTORY:
HABITS: Tobacco: None.
Caffeine: The examinee occasionally consumes one to two cups of coffee and tea.
Alcohol: The examinee occasionally consumes six cans of beer.
MARRIAGE/CHILDREN: The examinee is single and has one biological child,
age 2, and one stepchild, age 15.
RECREATIONAL ACTIVITIES: The examinee enjoys playing video games and
staying at home. He enjoyed hiking and swimming.
SERVICE-RELATED
DISABILITY: None.
RE: *, *
DOS:
Page 6
PHYSICAL EXAMINATION
Need to import physical exam template.
REVIEW OF RECORDS
DIAGNOSTIC STUDIES
LABORATORY REPORTS
DIAGNOSTIC TESTING
DIAGNOSIS
DISCUSSION
CAUSATION
DISABILITY STATUS
AMA IMPAIRMENT RATING AND ANALYSIS
APPORTIONMENT
RE: *, *
DOS:
Page 7
FUNCTIONAL CAPACITY
FUTURE MEDICAL CARE
SOURCE OF ALL FACTS AND DISCLOSURE:
The source of all facts was the history given by the examinee and review of the previous examiner’s medical
reports. I personally interviewed the examinee, performed the physical examination, reviewed the history with
the examinee, reviewed the medical records provided, dictated this report and it reflects my professional
observations, conclusions and recommendations. Face-to-face time conformed with DWC guidelines. I declare
under penalty of perjury that the information contained in this report and its attachments, if any, is true and
correct to the best of my knowledge and belief, except as to the information that I have indicated and received
from others. As to this information, I declare under penalty of perjury that the information accurately describes
the information provided to me and, except as noted herein, that I believe it to be true. Labor Code 139.3 was
not violated. I declare under penalty of perjury I did not discriminate in any way against the parties to the
action or the injured worker in the evaluation process or in the content of this report. Assistance was provided
by ***, Historian, ****, Record Summarizer and *******, Assistant, all of whom were trained by Arrowhead
Evaluation Services, Inc.
Date of Report: ****. Signed this ____ day of ____ , 2025 at San Bernardino County,
California.
Sincerely,
Albert R. Swafford, M.D.
Board Certified Orthopaedic Surgeon
