Authorization & Occupational Fitness Assessment (Ofa) Form (Page 2 of 3) in pdf

CONFIDENTIAL INFORMATION

(

TO BE COMPLETED BY ATTENDING PHYSICIAN)

Patient’s name:

Date of Birth: __________________________________________

Date of injury/illness: _______________________

Expected date of return to work: ___________________________

Reason for absence:

Sickness

Injury

Occupational

Non-Occupational

Primary diagnosis: _________________________________________________________________________________________

Secondary diagnosis: _______________________________________________________________________________________

If psychiatric diagnosis, DSM AXIS I: ___________________________________________________________________________

Hospitalized:

Yes

If “Yes”, date admitted: _______________________ Date discharged: _______________________

Medications: ______________________________________________________________________________________________

Treatment: _______________________________________________________________________________________________

Date of first visit: __________________________ Date of most recent visit: __________________________________________

Date of next planned visit: _________________________ Frequency of visits: ________________________________________

When do you expect improvement? ___________________________________________________________________________

Names of other treating physicians: ___________________________________________________________________________

Functional Limitations:

Restrictions/limitations of function resulting from medications and/ or treatment and approximate duration: __________________

_________________________________________________________________________________________________________

Are there any medical restrictions that limit your patient’s functions or abilities?

YES –

please complete below

*PLEASE NOTE THAT TRANSITIONAL WORK IS AVAILABLE

Physical Limitations:

Duration - Comments

Walking:

short distances only

medium distances