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    Return To Work Note

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    crystalparich
    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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    Return To Work Note

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    crystalparich
    204 views1 page
    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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    Return to Work Note

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    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    204 views1 page

    Return To Work Note

    Uploaded by

    crystalparich
    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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    of 1

    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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