Return To Work Medical Evaluation Form
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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: ____
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