Employee Medical Report Sample

Employee Medical Status Report

Name               :   Danny Hopkins
Date of Birth     :   12/27/1986
Employee ID      :   882345
Position            :   Cook
Diagnosis          :   HNP
Treatment Rendered and Response :

Analgesia and Multivitamin

Medication required on a daily basis if any :

None

Mandatory Discharge Information : ded

Is Employee fit for duty ?    Yes  …….        No …….

What restrictions if any ? Duration of restrictions & specific limits eg : time, weight etc. :

None

Maximum Medical Improvement : Yes …..    No …….

The definition of Maximum Medical Cures as follows : The accepted legal standard holds that maximum cure is achieved when it appears probable that further treatment will result in no betterment of the employee’s condition. Thus, where it appears that the employee’s condition is incurable or that future treatment will merely relieve pain and suffering but not otherwise improve the employee’s physical condition, It is proper to declare that the point of maximum cure has been achieved.

Date                             : ……………………………

Physician’s Signature       : ……………………………

Physician’s Name(Print)    : …………………………….