Free D-39 Form - Nevada

PHYSICIAN'S AND CHIROPRACTOR'S PROGRESS REPORT CERTIFICATION OF DISABILITY
Patient's Name: Employer: Patient's Job Description/Occupation: Previous Injuries/Diseases/Surgeries Contributing to the Condition: Diagnosis: Related to the Industrial Injury? Explain:

Claim Number: Social Security Number: Date of Injury:

Name of MCO (if applicable)

Objective Medical Findings:

" "

None - Discharged Generally Improved

Stable

"

Yes

"
Yes

No

Ratable

"

Yes

"

No

"

Condition Worsened

"
No

Condition Same

May Have Suffered a Permanent Disability Treatment Plan:

"

"

" No Change in Therapy " Case Management " Consultation " Further Diagnostic Studies: " Prescription(s)

" PT/OT Prescribed " PT/OT Discontinued

" Medication May be Used While Working

" Released to FULL DUTY/No Restrictions on (Date): " Certified TOTALLY TEMPORARILY DISABLED (Indicate Dates) From: " Released to RESTRICTED/Modified Duty on (Date): From: Restrictions Are: " Permanent To: To:

"

Temporary

" " " "

No Sitting No Bending at Waist No Carrying No Pushing

" " " "

No Standing No Stooping No Walking No Climbing

" No Pulling " Other: " No Lifting " Lifting Restricted to (lbs.): " No Reaching Above Shoulders
Physician/Chiropractor Signature: D-39 (Rev. 7/99)

Date of Next Visit:

Date of this Exam:

Physician/Chiropractor Name: