5.4.1. MEDICAL STATUS REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Employee Name:

• Complaint:

• Date of treatment by attending Physician:

I am authorizing any health professional who treats me to provide me, my employer and the WCB with Information which will help with my return to work

• Employee:

  Sign

• Date:

ATTENTION ATTENDING PHYSICIAN

• The company requests your assistance by completing the attached form in full to facilitate a timely return to work.
  We require detailed Information in order to place this employee on suitable work during the rehabilitation period

• this employee is able to return to regular duties for his normal hours.

• this employee is able to return to modified duties for his normal hours for a period of

• this employee is able to return to modified duties for hours / day

• for a period of days,

• then to regular hour and regular duties

• this employes is to have the remainder of the day to recuperate and report for his normal hours the next day

Physical Restrictions / Limitations - Please check boxes

• Lifting

• Not above shoulders

• Not over Kg / Lbs. form floor to waist

• Not over Kg / Lbs. form waist to shoulders

• Other:

• Limbs

• Limited reaching, pushing with injured arm

• Limited grasping, squeezing, carrying with injured arm

• Use of opposite hand only

• Minimal

• Limit repetitive movements of the Hand / Arm / Wrist

• Other

• Mobility

• No prolonged standing

• No prolonged sitting

• No kneeling, squatting or crawling

• Sit down work only

• No bending or twisting

• Other

• Other Restrictions

• Keep wound clean and dry

• Must wear brace, splint, or sling

• Must attend Physiotherapy

• Other

• Comments:

• Date of nest appointment

• Attending Physician

• Billing Information

• Name:

• Address:

• Phone: