You've been diagnosed with an illness that impacts your ability to work, play and thrive.

You're overwhelmed by the prospect of doctors, employment issues, new expenses, loss of income and the mountains of paperwork standing between you and your benefits.

You're not alone.  We know what you're facing and we will show you the best way to navigate these new challenges.

The Disability Key blog and the Disability Key Website are designed to assist each person in his/her own unique quest to navigate through the difficult and often conflicting and misleading information about coping with a disability.

Carolyn Magura, noted disability expert, has written an e-Book documenting the process that allowed her to:

a) continue to work and receive her “full salary” while on Long Term Disability; and

b) become the first person in her State to qualify for Social Security Disability the FIRST TIME, in UNDER 30 DAYS.

Click on the "download" link to receive Carolyn 's easy-to-read, easy-to-follow guide through this difficult, trying process.

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Sunday, January 01, 2006

The Physician Key:Linking Your Symptoms to Disability

The Physician Key:Linking Your Symptoms to Disability










Introduction
You have read the Disability Overview Key, and you now have:
· A better understanding that the purpose of obtaining disability insurance benefits is to create a financial safety net for you and your family;
· A better understanding of the disability insurance options that may be available for you particularly, LTD and SSDI;
· An understanding that your primary role in this process is to gather all of the evidence necessary to prove that the symptoms of your disease render you disabled, and therefore, qualified for the particular disability insurance(s) for which you want to apply; and,
· Considered the option of selecting an Attorney to do the work for you at a significant cost, or own the process by doing the work yourself using disease-specific experiential assistance.
Having decided to do the work yourself, and having completed the Current Situation Checklist, you now need to understand how to get your Doctor(s) to understand how best to help you. This is the purpose of this document: The Physician Key.
The value of The Physician Key is threefold:
1. By reading the information contained herein, you will gain a better understanding of the fact that disability insurance proof evidence is NOT necessarily about a disease and its symptoms. It IS about the SPECIFIC AND DETAILED impact that those symptoms have on you; specifically, on your ability to perform the Normal Daily Living (NDL) activities of your life – both on the job and at home.
2. The information contained herein is segmented so that you can copy and create separate documents to use as templates for use in communicating to your Doctor(s).
3. To maximize the help you can receive from your Doctor(s), it is important to provide them with as much information as they need to better help you. DO NOT ASSUME THAT YOUR DOCTOR CAN EVEN FIND YOUR FILE OR TAKE THE TIME TO GATHER THE EVIDENCE ON HIS/HER OWN. If your want help, DO THE WORK FOR THEM; they will greatly appreciate it. Remember, most Doctors have never been educated about disability insurance themselves and by educating them, you are assisting them to help you.

This Physician Key is segmented into the following components:
o An overall explanation for the Doctor(s);
o An example of a letter from you to your Doctor(s) specifically asking them for what you need;
o A disease-specific (Multiple Sclerosis) medical history document that you complete to better remind your Doctor(s) about your symptoms and their specific impact on you;
o An example of a successful medical history document
o A blank copy of what the disability insurance industry calls a Physical Capacity Evaluation document (PCE) or a Residual Functional Capacity (RFC) assessment that allows your Doctor(s) to quantify the effect your disease symptoms have on you.

A Message to Your Doctor
Your patient is in the process of attempting to qualify for disability benefits from either an insurance carrier or the Social Security Administration. They will need specific details when documenting their symptom’s impact on a Functional Capacity Evaluation (PCE) form. Note: this process might also be called a Residual Functional Capacity [RFC] assessment. It is used extensively by the Social Security Administration (reference form #SSA-4734.)
The patient has provided the following explanation so that you can better assist them in completing the necessary forms. The patient also has taken the first step in completing the form documenting symptoms as they impact daily functions. If you have a difference in opinion about your patient’s perception, please resolve the differences with the patient before completing the form.
Defining Disability
Doctors with patients who have been injured or have Social Security disability and/or long term disability claims are usually asked to provide evidence. But what do the Social Security people mean by "disability?" And what kind of evidence do they need from doctors?
There is no universal definition of "disability." It depends on who is defining it – the Veterans Administration, Worker's Compensation, Americans with Disability Act, Social Security Administration, etc.
A functional capacity evaluation can be an essential tool in determining whether a patient is disabled for purposes of Social Security and Long Term disability benefits. It is one of the primary reasons for SPECIFICALLY documenting the impairment a disease or illness has on a patient’s normal daily living (NDL).
An individual will be determined to be disabled if his or her impairment meets or equals the requirements of the Listing of Impairments found in the Social Security Blue Book. This is a list of physical and mental illnesses that the Social Security Administration (SSA) considers to be so severe that they warrant an automatic finding of disability.
However, if an impairment does not meet or equal the Listing Requirements, the patient will be determined disabled only if s/he is unable to perform work s/he did in the past 15 years and s/he is unable to do any other type of work considering residual functional capacity, age, education, and work experience. It is important to know that the proof of impairment – the documentation of this impairment – is the responsibility of the patient and his/her supporting medical team.
An individual's residual functional capacity means what an individual can do despite the limitations of the individual's impairment. The tool used to determine a patient's RFC is the functional capacity evaluation, which assesses a patient's capacity to do work-related physical and mental tasks on a regular and continuing basis--which means eight hours a day, five days a week.
A useful functional capacity evaluation needs to assess three important areas:
· physical abilities,
· mental limitations, and
· other non-exertional impairments and restrictions
All of a patient's impairments that are supported by medical records, even those that are not sever, should be addressed in the functional capacity evaluation since the combination of impairments may adversely affect the patient's ability to work.
Physical Abilities
This section of the functional capacity evaluation should describe the patient's limitations regarding physical activities. All potential activities that might be required for a work situation should be addressed: sitting, standing, walking, lifting, carrying, bending, squatting, crawling, climbing, reaching, stooping, kneeling, and so on. The patient's ability to do particular types of repetitive motions should also be considered. Please bee sure to note any necessary restrictions on the patient's physical activities. For example, can the patient lift up to 10 pounds? Over 50 pounds? And how often can the patient engage in such activity? Never? Occasionally? Frequently?
Mental Limitations
This part of the functional capacity evaluation should fully describe any of the patient's limitations in understanding, remembering, and following through on instructions. Also, be sure to note any limitations the patient has with respect to responding appropriately to common work situations, such as the ability to handle work pressures, receive supervision, or relate to co-workers.
Non-Exertional Impairments
This part of the evaluation should include information on other factors such as a patient's pain, environmental restrictions, the need for rest breaks, and any side effects of medication. When describing pain, be sure to note any objective signs of pain, the degree of pain, and the frequency of pain experienced by the patient. The evaluation should also explain whether the patient will need unscheduled breaks because of pain.
Any applicable environmental restrictions should be included in the functional capacity evaluation, as well. Must the patient avoid exposure to dust, fumes, or smoke? Can the patient tolerate heights?
The evaluation should address the patient's need for rest breaks, time off, and effects of the patient's medication. Is it likely that the patient will miss days of work because of pain or the side effects of medication? All such limitations should be fully described as they will affect the patient's ability to do work.
It is very important that you are very specific about the occupational limitations (including additional information not requested on the forms, if necessary). Also, it is important that NO ONE assume that a symptom or illness will automatically equate to functional impairment. You cannot depend on common sense to tell you who is disabled under the Social Security law. For example: with Multiple Sclerosis patients, an MRI that shows lesions does not necessarily equate to physical impairment, without the Doctor providing the actual link examples for that specific patient. SSA evaluators do not necessarily assume an MRI, which shows demyelinating disease, equals vocationally limiting fatigue, for example, unless a medical professional makes and explains the connection.
Here are some more examples:
1. A 48 year-old construction worker has done heavy, unskilled labor since age 16. He has a 4th grade education and a "low/normal" I.Q. He can read only basic things, like inventory lists and simple instructions. His heart condition limits him to sedentary work. He is not disabled under Social Security law unless he has an additional limitation.
2. A 38 year-old machine operator has done unskilled, medium exertion factory work since graduating from high school. A cardiovascular impairment limits him to sedentary work, and a permanent injury of the right hand limits him to work not requiring bi-manual dexterity. He is disabled under Social Security law.
3. A 61 year-old truck driver has been driving trucks all his life. But during a downturn in the trucking industry ten yeas ago he worked 18 months at a sedentary office job for his brother-in-law. Now a pulmonary impairment limits him to sedentary work. He is not disabled under Social Security law because he is still capable of doing the office job.
The Social Security Administration (SSA) defines disability as:
"Inability to perform substantial gainful activity by reason of a medically determinable physical or mental impairment, or combination of impairments, which has lasted or is expected to last at least 12 consecutive months, or end in death, taking into account the individual's age, education and work history."
The ultimate decision regarding a patient's residual functional capacity rests with the SSA, or with an LTD Insurance company, which may request a functional capacity evaluation to be performed by its own medical consultants. However, the importance of a functional capacity evaluation done by the treating physician or other health care professional cannot be underestimated. After all, it is that person who is most knowledgeable about the patient's condition and any resulting occupational limitations. The treating health care professional's functional capacity evaluation can greatly assist a patient in obtaining much-needed disability benefits.
Thank you very much for taking the time to assist your patient in this difficult process.
Sample Letter to Doctor

Date

XXXX Fax # NOTE: You can use their addresses if you are writing to
ZZZZ Fax # them, instead of faxing the information.
A.

Dear Dr. ZZZZZ and Dr. XXXX:

I am in the process of working with the Social Security Administration (SSA) to qualify for Disability Insurance benefits. (or, I am in the process of working with my long term disability (LTD) company to quality for LTD insurance benefits.) My appointment is scheduled for Tuesday, MONTH 17, 2222. I am taking the liberty of faxing this information to you and request that you fax back to me (111-111-1111) the requested information no later than Deadline Date.
Your assistance is needed in this process as follows:
1. Attached is a document that explains what I need from you, why I need the information and how to make the direct links between my illness symptoms and their impact on my life.
2. Attached is a copy of a Residual Functional Capacity Questionnaire for you to complete on me, based on your findings. I have completed my own, as I see myself impacted, and have attached it for your information.
3. A letter to the SSA, (or to the LTD Insurance Company) on your letterhead, stating that you have been treating me since (appropriate date for Dr. XXXX; appropriate date for Dr. ZZZZZ).
4. Your prognosis about my condition. (Dr. ZZZZZ is calling it chronic progressive. If your opinions are consistent, it will help the decision makers.)

5. Your prognosis about my ability to return to any type of work (never).
6. A statement about my overall physical condition. For example: I also am providing you by fax, a copy of how I believe that each bodily system is impacted by MS that I am providing to SSA/LTD. A statement could look like this:
Patient Name’s Multiple Sclerosis symptoms have been steadily increasing in magnitude since conclusive diagnosis through MRI and spinal tap in (appropriate date). The impact of these symptoms on the patient’s daily activities are adequately described in my chart notes, and in the patient’s diary notes.
Due to the magnitude, scope, and complexity of this patient’s condition, it is unreasonable at this time to expect that s/he will be able to work at any time in the near or distant future. At best, medication can only decrease the rate of increase of this chronic disease. In my opinion, this patient would be a liability to any employer, and would be unable to sustain gainful employment of any sort, due to her physical, mental, emotional, and psychological limitations.”
You may add that you had to cut the patient back in work hours from a “full time” of 60-40 hours per week to a “part time of 30 hours” in date, and to no more than 32 hours since Date.

The following SSA criteria for your information comes from their Blue Book, used to evaluate candidates for SSDI:
· Disability Evaluation Under Social Security also known as The Blue Book,
· Medical criteria for evaluating Social Security disability claims

Medical Evidence from Treating Sources
Currently, many disability claims are decided on the basis of medical evidence from treating sources. SSA regulations place special emphasis on evidence from treating sources because they are likely to be the medical professionals most able to provide a detailed longitudinal picture of the claimant’s impairments and may bring a unique perspective to the medical evidence that cannot be obtained from the medical findings alone or from reports of individual examinations or brief hospitalizations. Therefore, timely, accurate, and adequate medical reports from treating sources accelerate the processing of the claim because they can greatly reduce or eliminate the need for additional medical evidence to complete the claim.”

Finally, Dr. ZZZZZ, as my Primary Physician, could you please have a copy of all information in my medical file pertaining to the diagnosis of Multiple Sclerosis, including the old data dating back to the 1980’s. The information should include, but not be limited to: Doctor notes; chart notes; lab results; x-ray results; MRI results; Spinal Tap results; the chart notes from the Physical and Occupational therapists that I saw through Dr. PPPPP. (Note: I have Dr. PPPPP’s first write-up on me.)
I do not need this info by my SSA appointment date. However, as soon as possible would be nice. If someone could call me on OWN PHONE # I’ll come by in person and pick up the information.

B. THANK YOU BOTH FOR YOUR CONTINUED SUPPORT AND HELP!

MULTIPLE SCLEROSIS HISTORY Form
This form is provided as a way of reminding you of the key components of your illness. These components will serve as the starting point for completing all of your disability documents. They also often describe the reasons why your illness impairs your normal daily activities, both on-the-job, and at home.

1. NAME:___________________________ DATE:___________

2. SSN:_______________________

3. Age when you first experienced MS symptoms:________________

4. Year or age when you were diagnosed with MS:________________

5. In general, how has the course of your multiple sclerosis gone?

_______a few attacks with good recovery afterwards.
_______a number of attacks with at least some recovery.
_______slow progression with long periods of stability.
_______fairly steady progression without much recovery

6. What symptoms do you currently have related to MS?


SYMPTOM
EXPLANATION

Visual blurring or difficulty seeing colors


Double vision or jerky vision


Difficulties with concentration or memory


Depression


Facial pain


Loss of balance control


Rocking or spinning feeling


Difficulties with swallowing


Weak cough


Tremors


Tingling or feelings of numbness


Loss of feeling


Loss of strength in arms


Loss of strength in legs


Spasms or jerking in arms or legs


Difficulties with bowel


Difficulties with bladder


Spastic or uncontrolled movements


Headaches


Changes in sexual function


Easy fatigue


Heat sensitivity


7. Have you ever experienced:
_______ Skin breakdown (bed sore, decubitus ulcer)
_______seizure

8. Have you ever had:
_______Occupational therapy for__________________________
_______Physical therapy for_______________________________
_______Speech therapy for_______________________________

9. Do you have any type of regular exercise program or activity? ___No ___Yes; explain____________________________

10. Please describe your current activity level:


Activity level

Getting around on foot, but may have some limiting fatigue.

Getting around on foot, but using some assistive equipment (including braces, canes, crutches, walker, walls and furniture)

Able to take a few steps, but mainly relying on wheelchair or scooter

Able to move back and forth from wheelchair or scooter without help, but using wheelchair or scooter for all mobility

Using wheelchair or scooter, but need help with transfers

Spending much of time in bed

11. How often do you fall?__________________________________

12. Do you presently drive? ____Yes ____No
If no, date lost license:___________________
If yes, is your car equipped with hand controls? ____Yes ___No

13. Do you have a disabled parking permit? ____Yes ____No

14. Do you currently work outside the home? ____Yes ___No

15. Do you currently work inside the home (on activities other that “traditional” housework)? ____Yes ___No

16. If “yes” to either questions #14 and #15, are you working full time? ___Yes ___NO; Part time? ___Yes ___No

17. If “no”, are you on short term disability? ___Yes ___No
Long term disability? ___Yes ___No

18. Are you on Social Security Disability Insurance? ___Yes ___No

19. Are you retired? ___No ___Yes When:__________

20. Please indicate what assistive equipment that you currently use:


Assistive Equipment

Assistive Equipment

C. Brace

Reacher

Cane

Computer

Crutches

Cooling vest

Walker

Air conditioner

Wheelchair

Standing frame

Electric wheelchair

Bathroom grab bars

Power scooter

Bath chair or bench

Transfer board

Hand held shower

Toilet Assist seat

“Canadian” cane (arm assist)

21. Do you follow a special diet? ____No _____Yes If yes, does it work, and please describe briefly: _______________________________________________________________

Actually Completed MS Medical History form as an Example

MULTIPLE SCLEROSIS HISTORY

Actual example completed by Carolyn Magura; 45 years with MS; on LTD and SSDI; author of these examples.

D. This form is provided as a way of reminding you of the key components of your illness. These components will serve as the starting point for completing all of your disability documents. They also often describe the reasons why your illness impairs your normal daily living activities -–both on-the-job, and at home.


· NAME:___Carolyn Magura___________ DATE:_22-22-22

· SSN:_123-45-6789

· Year of age when you feel that you first experienced MS symptoms:_______15___________

· Year or age when you were diagnosed as having MS:___1986 “diagnosis of exclusion”; 1997 actual confirmation diagnosis

· In general, how has the course of your multiple sclerosis gone?
_______a few attacks with good recovery afterwards.
_______a number of attacks with at least some recovery afterwards.
_______slow progression with long periods of stability.
___X___fairly steady progression without much or any let up.

· What symptoms do you now have related to MS?


SYMPTOM
EXPLANATION
X
Visual blurring or difficulty seeing colors
Problems with “horizonal scanning”; brings on dizziness and nausea; weekly visual blackouts
X
Double vision or jerky vision
Wavy lines; holes of vision; right peripheral vision narrowing
X
Slowed thinking or difficulties with concentration or memory
Problems with “holes” in memory and speech; phone in freezer; not able to multi-task
X
Depression
On medication for 6+ years
X
Facial pain
And numbness of right side(about 25%); in 1993, mis-diagnosed with Bell’s Palsy on right side of face for 6 months
X
Loss of balance control
Consistently fall if not holding onto something
X
Rocking or spinning feeling
Any large visual situation, where the eyes need to move lead to dizziness and nausea.
X
Difficulties with swallowing
Had problems with swallowing; after testing, diagnosed with dysphasia.
X
Weak cough
Feel as though the chest is always “slightly full”, making a “deep breath” hard; comes with a weak cough. Has led to two (so far) major problems with pneumonia, going into bronchial asthma.
X
Tremors
In arms, fingers, legs, torso, feet, and head. Can no longer write by hand legibly.
X
Tingling or feelings of numbness

Also, heightened sensitivity in other areas; left foot and leg up to mid-thigh; right foot and up to mid-calf; scalp; fingers; arms; torso.
X
Loss of feeling
25% of right side of face; torso; feet; left leg; other areas at periodic times
X
Loss of strength in arms
Arms and fingers; also, problems with info from the brain going to the correct finger (i.e., e instead of I; w instead of p, etc. when typing).
X
Loss of strength in legs
Left leg very little strength; left foot drop, requiring support; right foot loosing strength.
X
Spasms or jerking in arms or legs
Causes MAJOR problems each night trying to get to sleep; when at rest, arms and legs jerk and spasm. Taking medication to lessen impact.
X
Difficulties with bowel
Sphincter muscles no longer close; problems when diet not strictly regulated, with loose bowels and too hard bowels. Wear protection 24/7
X
Difficulties with bladder
Problems with both incontinence and with inability to urinate. VERY FRUSTRATING!
X
Spasticity when move
Torso clinches like a charlie horse when I turn or twist
X
Headaches
Focused headaches, and aches in EVERY MUSCLE OF THE BODY. Medication to alleviate symptoms.
X
Changes in sexual function
Problems with loss of feeling.
X
Easy fatigue
MS is the only illness that I have found that combines insomnia with fatigue! When the twitching finally stops, and sleep kicks in, it is impossible to get up! Any activity taking longer than 10 minutes results in the need for rest/sleep. The fatigue is so bad that just the thought of activity is tiring.
X
Heat sensitivity
Heat only exacerbates the fatigue. Heat is to be avoided! BUT, even with 100 degree temp, feet are cold! Cooling vest and wool socks – what a look!

· Have you ever experienced…
___No_Skin breakdown (bed sore, decubitus ulcer)
___No_seizure

· Have you ever had:
___No__Occupational therapy
for__________________________
__Yes__Physical therapy
for___walking canes; foot brace; bathroom help; to be fitted for a scooter__
__Yes__Speech therapy
for_____help in sowllowing____

· Do you have any type of regular exercise program or activity? ___No _X_Yes; explain___stretching, balancing, and strength exercise program from Physical Therapy___

· Please describe your current activity level:


Activity level

Getting around on foot, but may have some limiting fatigue.
X
Getting around on foot, but using some assistive equipment (including braces, canes, crutches, walker, walls and furniture)

Able to take a few steps, but mainly relying on wheelchair or scooter

Able to move back and forth from wheelchair or scooter without help, but using wheelchair or scooter for all mobility

Using wheelchair or scooter, but need help with transfers

Spending much of time in bed

· How often do you fall?___frequently, if I do not have an assist of some sort_____

· Do you presently drive? ____Yes __X__No
If no, date lost license:__September 30th, 2002____
If yes, is your car equipped with hand controls? ____Yes ___No

· Do you have a disabled parking permit? X Yes ____No

· Do you currently work outside the home? ____Yes _X_No

· Do you currently work inside the home (on activities other that “traditional” housework)? __X_Yes ___No

If “yes” to either questions #14 and #15, are you working full time? ___Yes X NO; Part time? _X -volunteer_Yes ___No

If “no”, are you on short term disability? ___Yes _X_No
Long term disability? _X_Yes ___No

· Are you on Social Security Disability Insurance? __X_Yes ___No

· Are you retired? __X_No ___Yes When:__________

· Please indicate what assistive equipment that you currently use:


Assistive Equipment

Assistive Equipment
X
E. Brace
X
Reacher
X
Cane
X
Computer

Crutches
X
Cooling vest
X
Walker
X
Air conditioner

Wheelchair

Standing frame

Electric wheelchair
X
Bathroom grab bars
X
Power scooter
X
Bath chair or bench

transferboard
X
Hand held shower
X
Toilet Assist seat
X
“Canadian” cane (arm assist)

· Do you follow a special diet? ____No ___X__Yes If yes, does it work, and please describe: __As a result of the swollowing problems, I drink liquids with every meal; I also do not eat anything small that could get caught or that could go into the lungs; so, I use mashed potatoes or some other food to “collect” food for eating.

F.


PCE/RFC Form PHYSICAL CAPACITIES EVALUATION FORM

RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT FORM
Patient: SS #:
Date Of Birth:
Dear Doctor:
Please answer the following questions with regard to your patient's claim for Social Security disability benefits or Supplemental Security Income (SSI) and/or with regard to your patient’s claim for Long Term Disability (LTD). Please base your answers on how your patient's medical conditions affect his or her ability to function.
1.Nature, frequency and length of contact:2.Please describe patient's symptoms (including patient's reports of pain, dizziness, etc.):3.State all clinical findings and laboratory/test results (or enclose copy of same): Please link findings to specific limitations.4.Diagnosis:5.Treatment and response (including list of medications and their effect and side-effects):6.Prognosis:7.Has the patient's impairment lasted, or can it be expected to last, at least twelve months?Yes _____ No _____
8.Can the patient continuously stand for at least 6 of 8 hours?Yes _____ No _____ How long CAN the patient stand? ____________
9.Can the patient continuously sit upright for at least 6 of 8 hours?Yes ______ No ______ How long CAN the patient sit upright? ______
10.If the answer to either number 8 or number 9 is NO, why is the patient unable to sit or stand?11.Does the patient have to lie down during the day? Yes ______ No ______ If yes, please explain why:12.How many city blocks can the patient walk without stopping?
Please check the frequency that the patient can perform the following activities:
Rarely Freq. Const.
0-33% 34-67% 68-100%
Reach Above shoulder ______ ______ _______
At waist level ______ ______ _______
Below waist level ______ ______ _______
Handling (gross motor) ______ ______ _______
Fingering (fine motor) ______ ______ _______
Feeling ______ ______ _______
14. How many pounds can the patient frequently lift over an 8 hour period?_____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50

15. How many pounds can the patient frequently carry?____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50

16. Does the patient have any problems performing such functions as grasping, pulling, pushing, or doing fine manipulations with his or her hands? PLEASE BE SPECIFIC.17.Does the patient have any problems with the following movements? (Please indicate any applicable range of motion studies):Bending ______________________________________Squatting ______________________________________Kneeling ______________________________________Turning any parts of the body ________________________
18. Is the patient able to travel alone? Yes _____ No ______Why?

19. Are there any other factors affecting the patient's ability to work (e.g. exposure to fumes, gases; ability to tolerate heights; restriction of exposure to moving machinery)?
20. If your patient complains of any pain, please indicate the nature and severity of the complaints and your opinion of the patient's credibility with respect to his or her complaints:
If there is an objective basis for the patient's pain, give specific details for this basis (i.e. degenerative changes in the spine):21. Considering your diagnosis of the patient's condition and his/her prognosis, is the patient capable of returning to his/her past job?
Yes _____ No _____ State why or why not:
22. Considering the same factors, is there any work the patient is capable of? State why or why not:
Please note whether the above restrictions are:

____ Not likely to change.

____Temporary From:_________To:____________


Date patient can return to work:______________

_______Without Restrictions

_______With Restrictions as noted above


Please enclose copies of your clinical records on this patient. Use the space below for any additional comments you may have:

Date Report Completed:
______________________________
Signature of Physician:
______________________________
Physician Name:
______________________________
Address:
______________________________
Telephone:
______________________________
Specialty:
______________________________

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