Appendix Q

Name:________________________________ Date of Exam:_________________

 

Date of Injury:________________________   Date of Birth:__________________

 

Employer: ___________________________   Ooccupation:__________________

 

History as Related by Patient:
____________________________________________________________________

____________________________________________________________________

 

Are your findings consistent with history and type of injury?	Yes	No	Unsure
Is the injury work related?	Yes	No	Unsure
Are there any current conditions that may affect recovery?	Yes	No	Unsure
Please Explain: ________________________________________________

 

Diagnosis: __________________________________________________________

 

Treatment Plan: ____________________________________________________

____________________________________________________________________

 

Patient Status:	____ Return to work with restrictions (see below)
	____ May return to full duty work
	____ Unable to return to work

 

If unable to return to work full duty, anticipated date of return to full duty:___________

 

Work Status : (Circle the level of limitation if applicable)

 

Lifting:

 

___ Sedentary	<10 lbs occasionally and up to 5 lbs frequently
___ Light	10-20 lbs occasionally and up to 10 lbs frequently
___ Medium	20-50 lbs occasionally and up to 20 lbs frequently
___ Heavy	50-100 lbs occasionally and up to 50 lbs frequently
___ Very Heavy	>100 lbs occasionally and up to 100 lbs frequently

 

Bending	None	Occasional	Frequent	Constant
Squatting	None	Occasional	Frequent	Constant
Kneeling	None	Occasional	Frequent	Constant
Climbing	No fixed stairs	No Ladders
Reach	Not with Right	Not with Left
Grasping	Not with Right	Not with Left
Pushing/Pulling	Not with Right	Not with Left
Sit	None	Occasional	Frequent	Constant
Stand	None	Occasional	Frequent	Constant
Walk	None	Occasional	Frequent	Constant
Drive	None	Occasional	Frequent	Constant

 

Other:______________________________________________________________

___________________________________________________________________

 

Next Appointment Date and Time: ____________________________________

 

Health Care Provider Signature:__________________      Date:____________