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Claim Number (if applicable)
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CHIEF COMPLAINT
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RTW NO RESTRICTIONS
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RTW Date
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TTD
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TTD Appointment Date
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RTW with Restrictions
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RTW Date
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No Lifting
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No lifting over____ lbs
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No Repetitive squatting/kneeling
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No repetitive climbing/walking uneven surface
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No prolonged walking/sitting/standing
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Minutes per hour
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No repetitive reaching over shoulder
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Which Upper Extremity
• • •
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No forceful pushing or pulling
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Which Upper Extremity
• • •
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No Keyboarding
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No repetitive bending, stooping, twisting
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No repetitive finger, hand or wrist motion
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Which Upper Extremity
• • •
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No repetitive use of arm
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Which Arm
• • •
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No repetitive power grip
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Which Upper Extremity
• • •
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Sedentary Work Only
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Other
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Date of Next Appointment
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Dr. Nicola Signature (TURN ON)
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