PHYSICIAN’S AND CHIROPRACTOR’S PROGRESS REPORT CERTIFICATION OF DISABILITY Claim Number: Social Security Number: Patient’s Name: Date of Injury: Employer: Name of MCO (if applicable) Patient’s Job Description/Occupation: Previous Injuries/Diseases/Surgeries Contributing to the Condition: Diagnosis: Related to the Industrial Injury? Explain: Objective Medical Findings: “ “ None - Discharged Stable Generally Improved “ “ “ Yes No Ratable “ Condition Worsened May Have Suffered a Permanent Disability “ Yes “ “ Yes “ No Condition Same No Treatment Plan: “ No Change in Therapy “ PT/OT Prescribed “ Case Management “ Medication May be Used While Working “ PT/OT Discontinued “ Consultation “ Further Diagnostic Studies: “ Prescription(s) “ 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 “ “ “ “ No Sitting No Bending at Waist No Carrying No Pushing Date of Next Visit: “ “ “ “ No Standing No Stooping No Walking No Climbing Date of this Exam: To: To: “ Temporary “ No Pulling “ Other: “ No Lifting “ Lifting Restricted to (lbs.): “ No Reaching Above Shoulders Physician/Chiropractor Name: Physician/Chiropractor Signature: D-39 (Rev. 7/99) American LegalNet, Inc. www.FormsWorkflow.com