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Return To Work Medical Evaluation Form


To receive medical verification from your employees have their medical professional fill out the form below.




Return To Work Medical Evaluation Form



Return To Work Medical Evaluation Form


Employee's Name:

_________________________ ID# ___

Date of injury/surgery/onset or onset of illness: __/__/___ Date of Exam: ______

Diagnosis or description of injury/surgery/illness:

________________________________

The patients return to work status is:

[___] Return to regular work. Date: ____/____/____

[___] Able to return to work with noted restrictions. Date: ____/____/____

[___] Unable to return to work until next evaluation. Date: ____/____/____

[___] Referred to health care provider. Name ________ Date: ____/____/____

Lifting Restrictions:

[___] None
[___] 40 - 50 lbs.
[___] 30 - 39 lbs.
[___] 20 -29 lbs.
[___] 10 - 19 lbs.

Follow Up Plan of Treatment:

[___] None

[___] Return visit on: ______________ at________a.m./p.m.

Additional Comments:

________________________________

________________________________

________________________________



Health Care Provider's Signature

________________________________

Print Name

_______________________ Date_____

Phone Number: ____________________

Address: _________________________

City: __________ State: ___ Zip: ____





Word

PDF



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