This form was submitted by Stephen Savoie, DC.
"The IME form is one I have given to patients scheduled for an IME. I verbally explain what an IME is and what their responsibility to the exam are. I explain that this is an agent of the other party/insurer. I have them review the form and then pay attention to the time spent with the examiner. After the exam sit down and fill out the form, sign and date it. It has been very helpful when an attorney tells me there is a 12 page IME report stating my patient is perfect and I tell the attorney the exam lasted 3 minutes. We have had several exams retracted over the years. It's also humorous for the insurance company to find out they are paying hundreds for a 3 minute exam." Stated Dr. Savoie.
The form is in MSword format. You may want to edit it to include additional questions... did the doctor have you look up/down/left and right, have you smell things, or feel a cotton swab. You get the drill.. often one sees reports which state that all of the crainial nerves were normal, yet you are certain that they were never checked.
You may want to ask if the doctor pushed down on their head, or used an instrument to measure their range of motion.
Todd Narson, DC submitted the following:
The first page is similar to the one you already have, but the second page is more exam stuff. I've had many patient come back from the IME and after I've read the IME report to them and demonstrated what the various tests were, they said the IME doc never did any of it.
Patient Self Report Post IME