Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report (Page 4 of 8) in pdf

Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report Page 4

STATE OF CALIFORNIA

Division of Workers’ Compensation

PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)

Preclusions/Work Restrictions

Yes

Cannot

determine

Are there any activities the patient cannot do?

If yes, please describe all preclusions or restrictions related to work activities (e.g. no lifting more than 10 lbs. above shoulders;

must use splint; keyboard only 45 mins. per hour; must have sit/stand workstation; no repeated bending). Include restrictions

which may not be relevant to current job but may affect future efforts to find work on the open labor market (e.g. include lifting

restriction even if current job requires no lifting; include limits on repetitive hand movements even if current job requires none).

Medical Treatment: Describe any continuing medical treatment related to this injury that you believe must be provided to the

patient. (“Continuing medical treatment” is defined as occurring or presently planned treatment.) Also, describe any medical

treatment the patient may require in the future. (“Future medical treatment” is defined as treatment which is anticipated at some

time in the future to cure or relieve the employee from the effects of the injury.) Include medications, surgery, physical medicine

services, durable equipment, etc.

Comments:

DWC Form PR-3 (Rev. 01/01/05)

Form Pr-3 - Primary Treating Physician'S Permanent And Stationary Report Page 4