ࡱ> JLIu nbjbj]] 827f7f` xxxxx8\ $7DDDDDr7t7t7t7t7t7t7$u:+=7x7xxDD7222:xDxDr72r7226366D 9<4r4^77074=:v=866=x66("A2Ym_777=X >: FMLA / DISABILITY WORKSHEET (PLEASE NOTE: There is a $100 processing fee per set of forms, with a turnaround time of approximately 5-7 business days (excluding Saturday), AFTER all necessary documents have been received, payment is made and appointment has been kept. Thank you!) Patients Name: ____________________ Date of Birth: _____________ Please answer ALL questions to the best of your ability, ANY missing responses will delay the processing of your paperwork. What is your medical condition? (i.e. back pain, pregnancy, migraines, depression /anxiety, family member illness, etc.) ________________________ What is the approximate date the condition commenced? ________________________ What are / were your current symptoms? Please list. ________________________ Are you currently working? Yes or No? ________________________ is your leave intermittent/periodic days OR continuous/consecutive days? (SELECT ONE) ________________________ if leave is intermittent - Please estimate frequency & duration of absences Frequency / Duration: ____episode/s every ____ week/s OR ____ month/s with each episode lasting: ____ hour/s OR ____ day/s per episode What was the first date you missed work? ________________________ What is the expected/anticipated return to work date? ________________________ Have you been referred to a specialist re: your condition? Yes or No? ________________________ a) if Yes, please list type of specialist/s & their name/s ________________________ ________________________ b) if Yes, please list recommended treatment schedule (i.e. 1 visit, 1 time per week, for 4 weeks) ________________________ 8. Have you been hospitalized re: this condition? Yes or No? ________________________ a) if Yes, please list where & when. ________________________ 9. Have you had surgery related to your medical condition? ________________________ 10. Is this medical condition work related? ________________________ 11. LIST the job duties you cannot perform due to your condition. ________________________ DO NOT WRITE ALL or NONE, please LIST duties you normally ________________________ do when youre well. (i.e. interacting with customers, sitting, standing, ________________________ lifting, walking, talking on phone, working at a computer, driving, etc.) ________________________ ________________________ Once your forms have been completed & sent to requested persons, do you want your hard copy originals MAILED OR left at front desk for PICK UP? _________________________ 1/1/2020      (569HYZ     ! 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