Temporary Disability Evaluation Form
Patient Information
Name
Date of Birth
Patient ID
Disability Details
Diagnosis
Date of Injury/Onset
Expected Disability Period
Functional Limitations
Physician's Evaluation
Treatment Provided
Work Status
Full Duty
Modified Duty
Unable to Work
Work Restrictions
Next Follow-up Date
Estimated Recovery Date
Physician's Information
Physician's Name
License Number
Signature
Date