dob Page112/118 suvzor CALIFORNIA FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS no 1. msunu um: AND muss nu uo'r zuR.cR INSURANCE ATIN WORKERS cum: ATTN WORKERS cow. SCHALJMEURG I155 'nus cuLuMu 1.5MPLOVEI mus: MOYORS Nu Sn". "mum. ssuu rREMum awn FREMONYCA 5.53. Nan." a! (and mummy cansxluclmn alwnm-n's Cuunky: 5.. 5. "um mu: mad]. Ag. Khin u. .m .. .2 Nu 55.. FREMONT .. Mn 0.. v. 05.30.2015 5.. 5.. .5 and Nam .. szsyuu amalzma 5.. nun/cun- 5.. .mm. Dl-u- .. .. a. comm-l- mm. . .. comm-l- culcn mm In wavk'v's mmunnsulcn n. At: as." .u sxvosuns unvausn. Mama. ..5. mm. .. m. spans .5 magnumw n. m. "gm wniland cans-fl by ..5.. acxwumi anamy Iypmg and .5.. .5 .. .5 u. sul'EcnvE commqu u" v-wvis .. .. "names .. span. .. .. . :mhulalmg nmmal Maud .m PERRLA Hum-g m: nzvsi Umvhalynx m: nuflyinnsa CIA-xmplas "and .na rm murmur: unemnfik-l-l: Jami: any . Manual Ind-mu; mm llmlu Ron. and lung". 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Dan-M's Suanacmfl 2 Is malwm "may? s" mama a TREATMENT ms. mm. m. mm. span-1s Mammal 1. sum. a: mum. ind/Br mm". nun: . ngm. . pvusmalmn \s newsman mm :nsmg aux DIOR m. 511A Suam Munip-cmnd muich 1350:: and lemon at mm mm ugm ma Inmal ulna-ml" . snmum ssu m9 mumm- news) .my haul: by mal mun stpanssd my an mums) . cyclubnnzavvm- 7 5 m9 mm >Yakn mums>> 3 "mu 3 day by Mal vauls mum-n my 3n "mam - THERAPY REFERRAL- Selma-Ala wumn nvawdnv's an Evaluau a. Ilsa! slvam Dav 2 ma tun/15H: 2. sm nul um . pvusmalmn newsman mm :nsmg aux DIOR m. 525 015A Suam Mmuscl- unduly mum." will Mlhmax mual uncounlsv .m mm. . pvusmalmn \s newsman mm :nsmg aux DIOR m. M778 Ole-nmsinpalmni.Hal-Ii-wh-v- . IENustm/ms o: m: CARE INsWucnoNs mm" mummy-awn SD-cfly dwzuen . me MD wn renew up axAccEss ownnAR: an almmd ems/2m 5 nmspuama as Inpansnl g. . huSDHal "am. am lucanmv an. :flmul'd Mn Day alum-n flay much-fl 5 WORK sums . ws usual mm mu .m mum on] Rnpu vs slum mlmy mum-m Nun nun-um" Nut-l Dan-M has mummy-Mad Monmze euw many and mac: mmugh mm mm. up Wm a; < (id -. dob: --) Page 114/115 access 1 omnlcare Fafweil Medical Building 39150 F'dfwell Drive Fremonl CA 94535 Inspiring hen/Eh wellness AccessOmmcareLcm Phone: 510.555 2545 Fax 510.505.9257 WORK STATUS RECOMMENDATIONS FOR ENCOUNTER DATE: 07/18/2016 'ro Employer From Provider TESLAMOTCIRS I.. MANCHESTER, MD - CI Patient Name Khan. Ali Patientl lniury Specifics Date of injury 05/30/2016 lniury Spec s: . Reports progressively havrn ymptoms in his right wrist and hand ca sed by repet' ve tasks in work activities. Primar and mousing activities. Neck to mid hack have developed as well. lniury New: Pat nt presents for the evaluation and management of a new work related injury. Sex -- non -- Zflyo Phone Carrier zu CH INSURANCE Po yNoIder:'rEsLAMoToRs Based onthe availahle information, testing and clinical exam, the following assessmentts) and orders have been recommended: Diagnosis and 1. Strain of muscle and/or tendon of hand - Right - arders - The presentation is CONSISTENT with arising out ofOR occurring in the course of employment. 566.911A: Strain of unspecified muscle, fascia and tendon at wrist and hand level, right hand, initial encounter . naproxen sodium 550 mg taolet - Take 1 taoletfsl every 12 hours by oral route. Dispensed. Lot gosmo Exp Date: 03/01/2017 Dispense Qty: 30 taoletfsl . cyclooenzaprine 7.5 mg taolet - Take 1 taoletfsl 3 times a day hy oral route. Dispensed. Lot . coloe Exp Date: 03/01/2017 Dispense Qty: an taolet(s) . PHYSICAL THERAPY REFERRAL - Schedule Within: provider's discretion Evaluate Trea right wrist tendonitis, rhomhoid strain Visits per Week: 2 Total 1: of Visits: 6 2. strain of thoracic region - a The presentation IS CONSISTENT with arising out nfOR occurring in the course of employment. 529.01%: Strain of muscle and tendon of unspecified wall of thorax, initial encounter 3. Tendin of wrist - . The presentation IS CONSISTENT with arising out nfOR occurring in the course of employment. M77.8: other enthesopathies, not elsewhere classified . TENOSVNOVITIS or THE meT: CARE 4. strain of neck muscle Strain of muscle. fascia and tendon at neck level. initial encounter Work status Patient Instructions Repetitive strain injury, persistent. Need to refer to PT to assist in recovery. Discussion Notes The patient has been recommended MODIFIED beginning todayand in P_age115/11a place through to their follow up appointment. The work restri tions are is (o pins 20 minutes of keyhoarding/mnu 9 every hour or work Change posi ion often Stretch frequently Appointment Follow up Appointment scheduled: Troy I.. Manchester, MD for we FOLLOW UP at ACCESS on 07/25/2016 at 01:00 PM Electronically sinned bv: TROY MANCHESTER, MD KHAN, ALI -, Page 106/115 access omnlcare Farwell Medical 39150 Farwell Drive Fremonl CA 94535 Inspiring hen/Eh wellness AcceSSOmnIcare,ccm Phone: 510,555 2545 Fax 5105059257 WORK STATUS RECOMMENDATIONS FOR ENCOUNTER DATE: 07/28/2016 'I'o Employer From Provider TESLAMOTORS TROY I.. MANCHESTER, MD Patient llame Khan, Ali Patientl - cl 3 -- Injury Specifics Date of Injury 05/30/2016 Injury Spec s: . Reports progressively havm ymptoms In his right wrist and hand ca sed by repet' ve tasks in work activities. Primar and mousing activities. Neck to mid hack have developed as well. Injury Fol up Complex: Injury follow up with complex course of care. Status Report: Phy ns Status Report (PR-2) summa 9 care, orders and just ation. Sex - non -- zayo Phone Carrier ZURICH INSURANCE Po Holder: TESLA MOTORS Based onthe available information, testing and clinical exam, the following assessment(s) and orders have been recommended: Diagnosis and 1. Strain of muscle and/or tendon of hand - Right - arders - The presentation IS with arising out nfOR occurring in the course of employment. 566.911A: Strain of unspecified muscle, fascia and tendon at wrist and hand level, right hand, initial encounter - XR, CERVICALSFINE- Note to imaging Facility: 5VIEWS PLEASE Views CERVICAL SPINEI: AP, Ohliques, Lateral . XR, WRIST Side: views WRIST): PA, Lateral and Oblique - WRAP - Qty: 1 Unit Refil 'o Supplier: 2. Strain of thoracic region - . The presentation IS with arising out nfOR occurring in the course of employment. szgmeA: Strain of muscle and tendon uf unspecified wall of thorax, initial encounter 3. Tendimtis of wrist - - The presentation IS with arising out nfOR occurring in the course of employment. M77.8: other enthesopathies, not elsewhere classified . TENOSVNOVITIS or THE WRIST: CARE 4. strain of neck muscle Strain of muscle, fascia and tendon at neck level, initial encounter Work status Patient Instructions Repetitive strain njury. persistent. Need to refer to PT to assist in recovery. Discussion Notes The patient has been recommended MODIFIED beginning todayand in 110000070 (id- nge 107/118 place through to their follow up appointment. The work restrictions are as follows: 20 minutes of keyhoarding/mou every hour of work. Wear soft wrist wrap when keyhaa rding. Change position often Stretdl frequently Limit work weekto 8 hr days and 5 days per week. Appointment Follaw up Appointment scheduled: . Troy I.. Manchester, MD for wc FOLLOW HP at ACCESS on nil/0512016 at 06:00 PM . Michelle Jay, PT. for PT wc EVALUATION at PHYSICAL nil/0512016 at omzo AM Electronically SlunEd bv: TROY MANCHESTER, MD rm AODDOO71 KHAN, ALI dob: --) Page 18/118 Procedure Documentation Injury Follow up Camplex: Injury follow up with complex course of care. PR-2 Status Report: Physicians Status Report (PR-Z) summarizing care, orders and justification. Assessment Plan The course of the patients recovery is complicated by multiple issues as summarized, Patient presents today for follow up care regarding their open worker's compensation claim. The Interval history for the patient was reviewed and discussed in detail, Tendonitis of the right wrist, complicated by rhomboid strain and headathes. Minimal change. Will check on status for PT start. Had his initial evaluation, therapy to foIIow. Here today reporting a strong increase in pain in his upper back, pounding headaches during periods ofstress at work, He is very frustrated that he feels his supervisors are not understanding the needs of modified duty. Had episode ofacute headache, pounding, tightness in his shoulder when being acousted by co-worker. HR is involved. He is considering taking a leave ofabsence. Will continue medication, modifiy restrictions to 40 per week (though it was not restricted to that amount by workI and track progress with PT start this weekI and ergo changes at work are still pending. Solt wrist support to be used during computerwork. 1. Strain of muscle and/or tendon of hand - Right - . The presentation Is CONSISTENT with arising out of OR occurring in the course of employment, 566.911A Strain of unspecified muscle, fascia and tendon at wrist and hand Ievel, right hand, initial encounter 2. Strain of thoracic region - . The presentation Is CONSISTENT with arising out of OR occurring in the course of employment, 529.019A Strain of muscle and tendon of unspecified wall of thorax, initial encounter of wrist - The presentation Is CONSISTENT with arising out of OR occurring in the course of employment, M778: Other enthesopathies, not elsewhere classified 4. Strain of neck muscle - . The presentation Is CONSISTENT with arising out of OR occurring in the course of employment - Insurance Reportable 516.1XXA Strain of muscle, fascia and tendon at neck level, initial encounter Patient Instructions Patient status: WORSENING COURSE Will continue focus on physical therapy to drive recovery. increase is due to continued muscular pain, Very important patient keeps to his restrictions. Discussion Notes The patient has been recommended MODIFIED DUTV beginning today and in place through to their follow up appointment, The work restrictions are as follows: 20 minutes of keypoarding/mousing every hour of work. Wear soit wrist wrap when keyboarding. Change position often Stretch frequently work week to 8 hr days and 5 days per week, Return to Office - Michelle Jay, PT. for PT wc TREATMENT at PHYSICAL THERAPY on 08/18/2816 at 01:80 PM - Jonathan Hall, PTA for PT wc TREATMENT at PHYSICAL THERAPY on 08/19/2816 at 04:45 PM - Troy L, Manchester, MD for wc FOLLOW UP at ACCESS on 08/24/2816 at 04:20 PM Encounter Signcoff Encounter signed-off by Troy Manchester, MD, 08/17/2816. Encounter performed and documented by Troy Manchester, MD Encounter reviewed 8 signed by Troy Manchester, MD on 08/17/2016 at 5 18pm Encounter Date: 08/15/2016 Patient Name KHAN ALI (28yo, M) In- Appt. Date/rim: 08/15/2816 04 38PM Don -- Service Dept. PHYSICALTHERAPY AODDOOZS KHAN, ALI -, Page 86/115 access omnlcare Fan/v9" Medlcal 39180 Farwell Drlve Fremonl CA 94538 (lisp/ring hen/Eh wet/m; AccessOmnlcare corn Phone: 510 555 2545 Fax 510505 9257 WORK STATUS RECOMMENDATIONS FOR ENCOUNTER DATE: 08/17/2016 'ro Employer From Provider TESLAMOTORS I.. MANCHESTER, MD -CI Patient Name Khan. Ali Patientl lnjury Specifics Date of Injury 05/30/2016 lnjury Spec s: . Reports progressively havrn ymptoms In his right wrist and hand ca sed by repet' ve tasks in work activities. Primar and mousing activities. Neck to mid back have developed as well. lnjury Fol up Complex: Injury follow up with complex course of care. PR--Z Status Report: Phy ns Status lteport (PR-2) summa just ation. Sex - non M-- zayo Phone care, orders and Carrier ZURICH INSURANCE Po Holder: TESLA MOTORS Based onthe available information, testing and clinical exam, the following assessment(s) and orders have been recommended: Diagnosis and 1. Strain of muscle and/or tendon of hand - Right - arders - The presentation IS CONSISTENT with arising out nfOR occurring in the course of employment. 566.911A: strain of unspecified muscle, fascia and tendon at wrist and hand level, right hand, initial encounter 2. Strain of thoracic region - . The presentation IS CONSISTENT with arising out nfOR occurring in the course of employment. 529.01%: Strain of muscle and tendon uf unspecified wall of thorax, initial encounter 3.1'endin' of wrist - The presentation IS CONSISTENT with arising out nfOR occurring in the course of employment. M77.8: other enthesopathies, not elsewhere classified 4. Strain of neck muscle - . The presentation IS CONSISTENT with arising out ofOR occurring in the course of employment - lnsurance Reportable 516,1xxA: Strain of muscle, fascia and tendon at neck level, initial encounter Work status Patient Instructions 'ent status: WORSENING nouns: con ue focus on physical therapy to drive recovery. increase is due to con inued muscular pain.Very important patient keeps to his restrictions. niscussion Notes The patient has been recommended MODIFIED nun beginning todayand in place through to their follow up appointment. The work restrictions are as to ows: 20 minutes of keyhoarding/mou in every hour or work. Wear sort wrist KHAN, ALI - wrap when keyhaa rding. Change position aften Stretdl frequently Limit wark weekto 8 hr days and 5 days per week. Page 87/118 Appointment Follaw up Appointment scheduled: . Miche Ie Jay, PT.for PT wc TREATMENT at PHYSICAL nulls/2016 at 01- 0 PM . Jonathan Ha PTA for PT wc TREATMENT at PHVSICAL TNERAPV on nil/1912016 at 04:45 PM - Tray I.. Manchester, MD for wc FOLLOW HP at ACCESS on nil/2412016 at 04:20 PM Eiectromtally SmnEd bv: TROY MANCHESTER, MD rm AODDOOGO Page 56/118 KHAN, ALI dob Halli} 6 Thomas Vaug hum: Wade Hill -@tesla.com> sent Monday, July 13, 2016 1.37 PM 1a: Thomas vauger c: Carole Subject FW: Workers Compensation inrarmarlon Amshmem: Lad! importance: HiThomas, Please accept this email as autnonzaudn treat our All Khan, tor an alleged workrvelaled "11qu Let me knuw it you haye any questions Thanks! Wade Hill Sr. Workers Compensation Analyst 455% Fremont Boulevard CA 94535 510 249 2557 eFax 510 952 4535 e-Qlesla cum :1 the Benefits Team at 555.353.5041' Monday in Frlday from 5 a to 5 PT This e-mall message Is intended enly lorms use oilna named above liyor are not an lntendad reopen: you may not review' copy or this message ll you have received wmrnunlcallon in error please nolrly the sender immediately by ermall and delete lne or glnal message meiwade Hill 5: av, July 15, 2016 11:51 AM 1 Ii An" WCadmm flaw>> Suki-n: Workers compenurlon lnlormarlon Impnnanoe: High HiAlir I understand thatyau wnuld tn start the process for filing a warkerscumpensatlon (him. since Kalser is not In approved pruvider under resla's workers compensation carrier, Zurlch, me first step wauld include an evaluation at an approved Occupational Medicrne run which is located in Fremunl Since Tesla has an [Medical vrouider Network], rne expectation is mat employees will seek treatment at an approved tor the hrs! days, A transfer of rare can he discussed w/ your claims adjuster at Zurich lr treatment is still needed alter this initial timetrame. Access amniCare 391m Falwell Drive, suite 231 Fremont, CA 9453! ACCESS ommcm: . 391m FARWELL DR FREMONT co 94533-1000 KHAN, ALI (id- do _l stare of camamla, of Workers' Cumpensatlon REQUEST AODDO132