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New Assessment
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Today's date
Date of injury
Arrival time
Time in
Time out
Description of injury
Diagnosis
Work return status
Return to regular duty on
Return to work with temporary restrictions on
Return to work with permanent restrictions on
Unable to work
through
Reason
Reevaluate patient
days
Specialty referral
days
Specialty/Provider
Instructions
Workload
Sedentary work
Very light work
Light work
Medium work
Medium heavy work
Heavy work
Very heavy work
Upper body restrictions
Left side
Right side
Either
Both
Work hours per day
Decimal values are allowed.
Work hours per week
Decimal values are allowed.
Work days per week
Numeric values are allowed.
Walk
Never
Seldom
Occasionally
Frequently
Continuously
Stand
Never
Seldom
Occasionally
Frequently
Continuously
Sit
Never
Seldom
Occasionally
Frequently
Continuously
Crawl
Never
Seldom
Occasionally
Frequently
Continuously
Drive
Never
Seldom
Occasionally
Frequently
Continuously
Bend
Never
Seldom
Occasionally
Frequently
Continuously
Waist Twist
Never
Seldom
Occasionally
Frequently
Continuously
Work floor to waist
Never
Seldom
Occasionally
Frequently
Continuously
Work waist to shoulder
Never
Seldom
Occasionally
Frequently
Continuously
Work over shoulder
Never
Seldom
Occasionally
Frequently
Continuously
Squat
Never
Seldom
Occasionally
Frequently
Continuously
Kneel
Never
Seldom
Occasionally
Frequently
Continuously
Climb ladder
Never
Seldom
Occasionally
Frequently
Continuously
Climb stairs/steps
Never
Seldom
Occasionally
Frequently
Continuously
Foot (repetitive motion)
Never
Seldom
Occasionally
Frequently
Continuously
Hand coordination
Never
Seldom
Occasionally
Frequently
Continuously
Grasp
Never
Seldom
Occasionally
Frequently
Continuously
Grip
Never
Seldom
Occasionally
Frequently
Continuously
Pinch
Never
Seldom
Occasionally
Frequently
Continuously
Reach
Never
Seldom
Occasionally
Frequently
Continuously
Wrist Twist
Never
Seldom
Occasionally
Frequently
Continuously
Push/pull
Never
Seldom
Occasionally
Frequently
Continuously
Wrist flexion/extension
Never
Seldom
Occasionally
Frequently
Continuously
Keyboard work
Never
Seldom
Occasionally
Frequently
Continuously
Splints
Add Splint/Brace
Medications
Add Medication
PT
OT
Immobilizer
Ice
Heat
Elevate
Crutches
Sutures
Keep wound clean and dry
Boot
Corset
Sling
Cane
Use caution when walking on uneven/slippery surfaces
Alternate sitting/standing/walking as needed
Other information
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