Physician’s Disability Assessment
Patient Information
Full Name
Date of Birth
Patient ID/Number
Date of Assessment
Diagnosis
Primary Diagnosis
Secondary Diagnosis (if any)
Functional Limitations
Describe the patient's functional limitations
Current Treatment
Current Treatment Plan
Prognosis
Prognosis for Recovery or Improvement
Disability Status
Expected Duration of Disability
Temporary
Permanent
Unknown
Capacity to Work (if applicable)
Full Capacity
Modified Duties
Unable to Work
Physician Information
Physician's Name
License Number
Contact Information
Signature
Date