- Please describe your medical area of expertise and the length of time you have treated the patient.
- Please give a brief description of the patient’s medical history and diagnoses.
- Please describe what symptoms the patient has and is likely to experience on an average day as a result of a medical impairments.
- If the patient were to return to a full 40-hour workweek, describe what work accommodations would a require.
- Using hands (typing, writing, etc.)
- Unscheduled Absences or Extra Work Breaks
- In your medical opinion, will the problems you described in question #4 present themselves at least two or three times a week? Yes No (If yes, feel free to explain.)
- In your medical opinion, are the patient’s subjective complaints within the range of what can be expected from individuals with the same type of medical conditions?
- Yes, the patient is being forthright with a symptoms
- No the patient is malingering
- Have these limitations existed to the extent described since ________ (insert date)? Yes No
Please feel free to provide additional comments or explanations.
Doctor's Signature: ___________________