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 NoUnsure
Is the injury work related?  Yes No Unsure
Are there any current conditions that may affect recovery? YesNoUnsure
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)
___ 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
___ Heavy50-100 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    OccasionalFrequentConstant
Climbing No fixed stairs No Ladders  
ReachNot with RightNot with Left  
Grasping  Not with Right  Not with Left  
Pushing/Pulling      Not with Right     Not with Left       
Sit   None Occasional Frequent     Constant
Stand NoneOccasional Frequent Constant
Walk  None Occasional FrequentConstant
Drive None OccasionalFrequent  Constant
Next Appointment Date and Time: ____________________________________
Health Care Provider Signature:__________________      Date:____________
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