I understand that I am here for an Independent Medical or Impairment Examination (IME) with Jonathan Paul, MD; this means the doctor performing the evaluation is neither treating me nor an employee of whomever requested the IME (insurance company, third party administrator, attorney, governmental agency, employer, or physician). The purpose of the IME is to provide a thorough, objective evaluation of the specific condition(s) related to the injury or illness in question, as well as prior or subsequent conditions that may affect it, and answer whatever questions the requesting party has. This document outlines the IME process, my rights, and my responsibilities.

This IME is not a comprehensive medical examination. It will not provide advice or treatment or substitute for evaluation or treatment by my regular treating doctor. A patient-physician relationship is not established between the evaluating physician and me. Accordingly, there is no patient/physician privilege associated with this evaluation. Usually, a written report will be prepared summarizing today's evaluation and sent to the requesting party. If I would like a copy of the report, I will contact them.

I understand that generally my evaluation will begin with the doctor obtaining a history of how my problem began, and what evaluation or treatment has been rendered since; utilizing information I provide verbally, and document on the history forms; as well as that contained within whatever records may be available for review. The doctor will then ask about my current symptoms and generally record a relatively brief past medical history, and other information such as my work status, etc. All information I provide may be included in the report.

After the interview, a physical examination of the relevant body part(s) will be conducted. I understand that I need not perform any maneuver I feel might cause injury or a worsening of my symptoms and will immediately inform the examiner if anything he/she is doing is causing excessive discomfort so it can be stopped right away. Some pain, stiffness, or other symptoms are produced in most physical examinations of this sort, for instance, when touching a tender spot or checking how far a stiff joint can move, and such findings clarify my condition. The IME, however, is not intended to cause injury or excessive pain. I understand that to avoid that, I must fulfill my responsibility to inform the doctor(s) if there is something I can't do, or if a certain test is causing too much discomfort, etc.

I also understand that I am permitted to have a chaperone present during the physical examination, at my request. I consent to the taking of digital photographs to document findings during the physical examination. Dr. Paul uses CarePilot Electronic Medical Record recording to capture a written transcript of the entire history and physical exam for accuracy. I understand I have the right to record this examination, either using video or audio.

I have read and understand the aforementioned information and instructions. I authorize this physician or any co- examiner to obtain any information that may be of relevance to the condition(s) in question, and to release that information and results of this IME, (verbally or in writing) to the entity that has requested the IME.

Prior Injury 1

Prior Injury 2

Prior Injury 3

Prior Injury 4

What are your physical limitations? What are you physically unable to do, or can you no longer do since the accident?

If so, are there any restrictions doing so?

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Thank you for your assistance. At the time of the visit, we will review this information in further detail.