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Return to Work Medical Evaluation Form

Crystal Parich was diagnosed with the flu and a sinus infection on February 6, 2024. She saw Dr. Candice Demattia on February 13, 2024 for a return to work evaluation. Dr. Demattia determined Parich could return to regular work duties as of February 13, 2024 with no lifting restrictions. Parich was told to return for another flu test before returning to work to ensure she was no longer contagious.

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596 views1 page

Return to Work Medical Evaluation Form

Crystal Parich was diagnosed with the flu and a sinus infection on February 6, 2024. She saw Dr. Candice Demattia on February 13, 2024 for a return to work evaluation. Dr. Demattia determined Parich could return to regular work duties as of February 13, 2024 with no lifting restrictions. Parich was told to return for another flu test before returning to work to ensure she was no longer contagious.

Uploaded by

crystalparich
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
  • Return to Work Medical Evaluation Form

Return to Work Medical Evaluation Form

Employee’s Name: __________________________________


Crystal Parich ID# ____________________
8903 .
Date of injury/surgery/onset or onset of illness: _____________
02/06/2024 . Date of Exam: ____________
02/13/2024 .
Diagnosis or description of injury/surgery/illness: ___________________________________________
Flu and sinus infection. .

The patients return to work status is:


[__] Return to regular work. Date: _____________
02/13/2024
[__] Able to return to work with noted restrictions. Date: _____________
[__] nable to return to work until next e aluation. Date: _____________
U v

[__] Referred to another health care pro ider. Name _______________________ Date:____________
v

Lifting Restrictions:
[__] None
[__] 40 – 50lbs.
__
[ ] 30 – 39lbs.
__
[ ] 20 – 29lbs.
[__] 10 – 19 lbs.

Follow Up Plan of Treatment:


[__] None
[__] Return isit on: __________________________.
v

Additional Comments:
Patient came in on 02/10/24 after having the flu the week before. Patient tested positive for the flu and
was diagnosed with a sinus infection. Patient was told to come back for another flu test before being
able to return to work.

_____________________________ _______________
02/13/2024
Health care provider signature Date

Health Care Provider’s Name: _________________________________________________________


Dr. Candice Demattia
Phone Number: _____________________________________________________________________
281-255-3838
Address,City and State,Zip: ___________________________________________________________
506 Graham Dr., Tomball TX 77375

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