ATTENDANCE
__Unable to return to work until further notice
Unable to return to work until: ________
Patient must attend hand therapy _________________
__Unable to work until after next office visit
ACTIVITY
Return to work on _________ with these restrictions:
No use of __right __left __either hand
Limited use of __right __left __both hands as noted below: __Frequent __Infrequent __None
Pushing __Frequent __Infrequent __None
Pulling __Frequent __Infrequent __None
Two handed lifting __Frequent __Infrequent __None
Reaching overhead __Frequent __Infrequent __None
Climbing __Frequent __Infrequent __None
Repetitive lifting __Frequent __Infrequent __None
Writing __Frequent __Infrequent __None
Fine manipulation __Frequent __Infrequent __None
Apply strong torque (turning force) __Frequent __Infrequent __None
Lift as much as _____ pounds
Lift more than _____ pounds
Temperatures less than 60 degrees F __Frequent __Infrequent __None
Exposure of hands to liquids __Frequent __Infrequent __None
Exposure to solvents or chemicals __Frequent __Infrequent __None
Heavy soilage of hands __Frequent __Infrequent __None
Working with rapidly moving machinery __Frequent __Infrequent __None
Working with vibrating tools __Frequent __Infrequent __None
Other:
__Splint must be worn __Bandage must be worn
10 - 30 second break for stretching exercises every _______minutes.
___If work is not available within these restrictions, then patient is unable to work
__Work restrictions effective until further notice
Work restrictions effective until:______________
Return to work on _________ with no restrictions