Treatment program's notice to WCB that a worker has been taken into a secondary or tertiary program.
- Completed by
- Accredited secondary/tertiary treatment program clinician
- Issued by
- WCB Saskatchewan
- Format
- Language
- English
WCB Saskatchewan Functional Examination Record
This four-page WCB Saskatchewan record is a structured template for a physical examination of an injured worker, centred on the upper quadrant. It records range of motion and strength for the shoulder girdle, shoulder, elbow, wrist and spine, then reflexes, myotomes, cranial nerves and palpation findings. Special tests for the jaw, neck, shoulder, elbow and wrist and a lower body biomechanical scan complete it.
Who completes it
WCB Saskatchewan lists it among its care provider forms without naming a profession; the examiner records the date, patient name and claim number, then findings for the right and left sides.
Submitting and payment
- How to submit it
- The record gives no submission instructions; its header lists the email and fax contacts of WCB Health Care Services, and correspondence should carry the worker's name and claim or firm number.
Good to know
- Page 2 grids reflexes from C4 to T1 plus Babinski, Hoffman's and clonus, and myotomes from the C3-4 shoulder shrug to T1 interossei, each marked right, left or normal.
- Cranial nerve tests run from olfactory (smell) to hypoglossal (tongue protrusion), with vestibulocochlear checks that include Weber's test and a finger rustle.
- Special tests include cervical ligament stability, compression, distraction, upper limb tension and vertebral artery tests, shoulder impingement and apprehension, and Phalen's and Allen's tests.
- Page 4's biomechanical scan covers lumbar positional tests, hip tests such as FABER and Thomas, knee ligament tests with McMurray's and Apley's, and ankle ligaments.
Get the official form
Download the current version from the source each time; forms change without notice.
Functional examination record
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
What does the WCB Saskatchewan functional examination record cover?
Mainly the upper quadrant: posture, dermatomes, pain and light touch, range of motion and strength for the shoulder girdle, shoulder, elbow and wrist, cervical and thoracic movement, and resisted movements. Later pages add reflexes, myotomes, cranial nerves, tenderness to palpation, special tests and a biomechanical scan of the lumbar spine, hip, knee and ankle.
How is the jaw assessed on the record?
Page 3 records jaw opening and lateral deviation to the right and left in millimetres, oral habits, tongue position (palate, floor or between the teeth), tongue thrust and whether the patient breathes through the mouth or nose. It sits beside the cervical special tests and a palpation chart of the jaw and neck muscles.
How are palpation findings recorded?
A numbered skeletal and soft tissue chart marks right and left sites, including the sternocleidomastoid, the scalenes, suprahyoids, prevertebral muscles and subscapularis. Codes show whether each site is tender, sore, stiff, in spasm or hypermobile, or held extended or flexed, and page 2 adds tenderness at the shoulder, elbow, wrist and hand.