Independent Medical Examination (IME) Report

Independent Medical Examination (IME) Report

(Use absolute calendar dates throughout; do not use relative time references. Maintain neutral, objective language. Attribute all examinee statements with "The examinee reports..." or similar. Separate facts from records, examinee-reported history, examination findings, and opinions.)

Examiner: [Name], [Degrees/Credentials], [Specialty], [Board certifications], [License number and state], [Practice address], [Contact information]

Requesting Party: [Name], [Organization], [Contact information]

Examinee: [Full legal name], [Date of birth], [Claim/Case number], [Date(s) of injury or exposure], [Employer if applicable], [Jurisdiction]

Examination Date: [Date]

Examination Location: [Facility and address / telehealth platform and originating site]

Format: [in-person / telehealth / records-only review]

Report Date: [Date]

Engagement Statement and Disclosures

(State that this is a third-party medico-legal evaluation, not a treatment encounter, and that no physician–patient treatment relationship is established. State that opinions are rendered objectively based on available records and examination findings.)

• Prior involvement with the examinee: [None / description of prior involvement]
• Compensation disclosure: [Compensation is for professional time only and not contingent on outcome]
• Notice and consent: [The examinee was informed of the purpose and third-party nature of the evaluation and agreed to proceed]
• Incidental findings process: [Clinically important incidental findings, if identified, will be communicated with guidance to seek follow-up]

Referral Questions

(List each question verbatim as numbered items. If provided verbally or in a cover letter, state source and date. If no specific questions were provided, state this and define the issues being addressed and why.)

1. [Verbatim referral question]
2. [Verbatim referral question]
3. [Verbatim referral question] (Add additional items as needed)

Standard of opinion: [Reasonable medical probability / other applicable standard]

Sources of Information

(List all materials reviewed. Distinguish medical records from non-medical materials. Identify sources of history. Comment on completeness and notable gaps. If materials were received but not reviewed, list separately with explanation.)

• Medical records reviewed:
  • [Document type], [Author/Source], [Facility], [Date(s) of service], [Notes on completeness or legibility]
  • (Repeat for each record)
• Non-medical materials reviewed:
  • [Item type: job description / accident report / witness statement / FCE / surveillance summary], [Source], [Date]
  • (Repeat for each item; omit subsection if none)
• Sources of history: [Examinee interview / Accompanying person with relationship / Interpreter with language / Questionnaire]
• Record set completeness: [Appears reasonably complete / Significant gaps noted: specify missing timeframes or key items]
• Records received but not reviewed: [List items and reason not reviewed] (Omit if none)

Records Chronology

(Provide a neutral, factual timeline of documented events: injury/exposure date and immediate care; key diagnostics with dates; treatment course with dates and documented response; work status changes; relevant prior injuries/conditions when documented. Cite sources inline. Reserve conclusions for the opinions section. If no records were provided, state: "No contemporaneous records were provided; chronology is based on examinee-reported history only.")

• [Date] — [Event or encounter] — [Source citation: document type, author, date]
• (Add additional dated entries as needed)

Examinee-Reported History

(Include only if an interview was conducted; omit entirely for records-only reviews. Use attribution language throughout. Document uncertainty explicitly when details are not recalled. Use direct quotes sparingly for pivotal descriptors affecting diagnostic reasoning.)

Chief concern: [Examinee's stated primary reason for evaluation]

Reported mechanism of injury or exposure: [Examinee description including setting and sequence of events]

Symptom history: [Onset], [Progression], [Location and character], [Aggravating factors], [Alleviating factors], [Current severity], [Associated symptoms]

Functional impact: [Activities of daily living], [Mobility], [Sleep], [Driving], [Tolerances for sitting/standing/walking/lifting/carrying], [Use of assistive devices]

Treatments attempted and response: [Medications], [Therapy], [Injections], [Surgery], [Self-care measures], [Perceived benefits and adverse effects]

Relevant past medical and surgical history: [Pre-existing conditions affecting the involved body region/system], [Prior injuries], [Surgeries], [Other pertinent history]

Current medications: [Names, doses, frequencies]

Allergies: [Drug/other allergies and reactions]

Occupational history: [Job title], [Essential functions], [Physical demands], [Schedule], [Tenure], [Modified duty availability if known]

Relevant social history: [Tobacco], [Alcohol], [Substance use] (Include only if pertinent to the condition or referral issues)

Focused review of systems: [Pertinent positives and negatives relevant to referral questions]

Examination Conditions and Validity

(Describe factors affecting reliability. Use objective behavioral descriptors without pejorative labels. Omit items that do not apply.)

• Interpreter: [Language and modality] (If used)
• Chaperone/observers: [Present/not present; identity and role]
• Recording: [Permitted/prohibited; handling and notice provided]
• Examinee cooperation and effort: [Objective behavioral observations, e.g., consistency across maneuvers, variable effort on specific tests]
• Examination components refused: [Component and stated reason] (If any)
• Safety events or interruptions: [Description] (If any)

Physical Examination

(Include only if a physical exam was performed; omit entirely for records-only reviews. If a standard element was not performed, state why.)

Vital signs: [Values and units] (If obtained)

General appearance and function: [Appearance], [Gait], [Transfers], [Use of assistive devices]

[Body Region, e.g., Cervical Spine / Lumbar Spine / Right Shoulder]

• Inspection: [Alignment, scars, swelling, atrophy, deformity]
• Palpation: [Mapped tenderness distribution]
• Range of motion: [Degrees by plane]; [Method/instrument used]; [Pain-limited vs structural limit]
• Strength: [Muscle groups with grading scale specified]; [Pain inhibition vs true weakness if distinguishable]
• Sensation and reflexes: [Distribution, symmetry, modality]
• Special tests: [Named tests and results]
• Functional testing: [Relevant tasks: squats, heel/toe walking, grip tasks]

(Repeat region-specific blocks as needed for each body region examined)

Diagnostic Studies Reviewed

(Include when imaging, electrodiagnostics, laboratory studies, or other testing was reviewed. If providing an independent interpretation that differs from the formal report, label it explicitly. Omit section if no studies were reviewed.)

• [Date] — [Facility] — [Study type]: Formal impression: [Interpreting physician's impression]; Salient values: [Key measurements]
  • Independent interpretation: [Examiner's differing interpretation] (If applicable)
• (Add additional studies as needed)

Assessment

(Numbered problem list ordered by medico-legal salience. Include differential diagnoses when uncertainty materially affects causation, apportionment, or impairment. If diagnosis cannot be established, state "Diagnosis indeterminate due to [reason].")

1. [Diagnostic label with laterality/anatomic specificity]: [Status: acute/subacute/chronic; resolved/ongoing; at MMI or not if determinable]. Support: [Key records, examination findings, studies]. [Pertinent differentials if applicable]
2. (Add additional diagnoses as needed)

Medical Opinions

(Answer each referral question in matching numerical order. Keep each response self-contained so it can be extracted independently. Address only topics asked or directly necessary to answer them.)

Question 1: [Verbatim referral question]

Opinion: [Direct conclusion using applicable standard, e.g., "It is my opinion, within reasonable medical probability, that..."]

Rationale: [Factual and medical reasoning citing specific records by date/author, examination findings, and diagnostic studies; address contrary evidence and alternative explanations]

Limitations: [Missing information or uncertainties that could alter the opinion]

Question 2: [Verbatim referral question]

Opinion: [Conclusion with applicable standard]

Rationale: [Reasoning with citations]

Limitations: [Constraints]

(Add additional numbered question-response blocks as needed)

Recommendations

(Include when recommendations are requested or clinically necessary. If no additional recommendations beyond the opinions are warranted, state that briefly. Omit inapplicable items.)

• Further diagnostic evaluation: [Tests/studies needed and purpose]
• Treatment recommendations: [Type], [Frequency], [Duration], [Goals]; [Curative vs palliative/maintenance distinction]
• Work capacity and restrictions: [Lifting/carrying limits], [Pushing/pulling limits], [Overhead work], [Positional tolerances], [Fine motor demands], [Ability to perform essential job functions if demands known]
• Follow-up for incidental findings: [Actions and responsible party]

Limitations and Qualifications

(Document constraints on opinions. Do not infer that care did not occur when records are incomplete; document the gap and state how it limits conclusions. Include only applicable items.)

• [Incomplete records: specify missing timeframes/documents]
• [Time limitations impacting the evaluation]
• [Examination limitations: components not performed and reasons]
• [Examinee refusals: components and reasons]
• [Language barriers and interpreter limitations]
• [Telehealth-specific limitations] (If applicable)
• [Statement: Opinions are based on information available as of the Examination Date and Report Date]

Attestation

I, [Examiner name], [Credentials], [Specialty], [License number/state], attest that this report reflects my independent evaluation and opinions rendered to a reasonable degree of medical [probability / certainty per jurisdiction], based on the information available and the examination performed as documented.

Signature: [Electronic/physical signature]
Date signed: [Date]

Attachments: [Curriculum Vitae], [Impairment calculation worksheets], [Detailed records list], [Other attachments] (List applicable items)