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: