Mass Phone: 5103351545 Urgzm Cave
access 1 39190 Faxgg, Sun: 231 Fax: 5105055237 indmriai Iniunes
Fremonl.
L1 Empiuyer Services
Inspiring health 
SO WORK sums REPOII

Emplavee Mani Date or airr Daleofl jury'--
mere :11 mm 151--0
01:01me

 

unsui- sums
\zi inmaMsn Fulluw-up Vim i:i Yhismlurv has been ruled 

rim Aid Univ :1 Instr-<>l1v a MRI cr a i-_i orn mam
won sums
The perm in: bad! insmnadru:
. 
mum lull duty wirn no llmlullons arresrnmonsan 91 it
. u. "as m: pulhl'l/ 
a flu stairs :i no llhn'abfl" Muldmm' Mm
no kneeling squamn' criwlin' a nu iaendinreperime knollmg squmin. mMir' i: na mam "a "Mum mgr/hand work
a minimal use ur a no repemm mm" I m, Mywwi".
a no Mung at shnuldzr nu. i: sedan" I 5min! W'k 

 

ansunr (ea hams):
seldom hours) a ocnsimal (24 hours) i: (H naurs) 

fl 
ndin waunnl
hand/wrist wk a pouergrip i:i bendinl a mug . 3" :1 comm" um 
warhead a teaching in a pushing/9mm:
we mm m" MN "imam": in :i wemead work a reaming
i:i hand/wrist work a pawergny bending in usundifll 
in Other: 

 

 

 

remain of! work unul "an physician 1 16 15,24 mm-
- 1 .
estimated numblrofweeks umll full dutyEMPLOYEE SHOULD 55 or; WORKIFNO MODIFIED wan

0W sums

miuuc
I i1 i1 from engaging in her/hisusuai occupation in Pa iznrs (undillm is Permanent and summary. ream
:i Pane (permane {vamc 

mieniwili have permanent residuals.
Fatient will require future medlcal care.

Palm is a Quilified Injured Workev. 
a Mm in "new." mm .. 
GBP6 1 .
15 5733. '1 mt

Prim: MM WW Date: 34 Ii

  
   

Signature:



 

  
   
   
 
   

Mus gmmuu Phone: 5105851545 Urgem care
39150 FarweH Drive, m: 231 Fax 5105055287 Industrill Injuries
Fremont CA 54538 Employerervices

WORK STATUS REPORT
- .v El [5 I I8)


PATIENT sums

lniualvisu fiuuwup \flsit um: Injury has be!" a run Aid Only a memafiv: Resmmans

sum: [an ws|L symmamshave:

.mpnmu is mama :1 Improved slower than :xpmed

Imwved silniflcanflv a "named, no warsened

 

fiNmmu rm
DPmcedurepe armed:DanecKian mom .

mm Guard Mm. a a 

nngerrah ass: a om;


SIIYI 

um; I

 

 

 

SludyE. X-rlv :1 MM :7 cr a 00m: now Pm:

 

 

woszTATus
Yhe man has been unnamed m:

Hermann." um. um mun-"Emu": "mum," )ozew mm wk on 3 [2 ll 


 

  

 

o'iR'MIh-wewaistmd mum/mun.) ms
"own/,mwmm. 

no repetitive kuuling/ wumng criwiinz no mam a cue hind Wk unVy

mummy useof a nu <Access OmniCam

     

    

 
 
 
 

 

 

access 39150 Farwell om, Suite 231 
ommcare Fremont CA 54538 Emplover 52mm
health mums
wonx smus amm-
rmplave'm'" SJPY to") Ne' 5 Egufsinh are on ury I3 "9
omolmmt Time out: 4-01 Lucatlon:


 

PATIENT sums
Follow-up Visit this injurv has been ruled non-lndusmal First Aid only a Preventative 
5m las: Vlsil, symomms have: lmprovoo as women a Improved slower than Expected

not impmvad no impmvemenl expetled worsened

IREAYMENT
'gumws'ml'k diy; wzeks monlhs PM Dan

g-L'l-l'klmouflmam 1%ro

PMVCII Therapy: days a weekfar weeks Procedure paricvmed: El lnl'eclinn a other;

 

 

 

 

 

 

El Splint: So" [id Guavd Medsz DYC Pvescripticn

ukeferr . a other: a surgery:

mm

may a MRI cr memes omen army Parr
WORK STATUS

The pale!" has been lnsuumd Kn:

Vacuum: lull only nn or remifllonsun i 1% -- 13 mm moalfiod work on

worir 

 

a no hdders sulrs no above walsr leul m5. Cl nu pullm' loo.
a nu no shouldev level wark

a nu mpomnn no making one ham walk only

a mnlmol usgof no room>>: reaching l:l no renown: MIR/hand walk

a no Mm: anhauldu level lbs. xedenlary 5min work only a no power [rlumn'

seldom (M hows] nacaxiarlzl (24 hours) l:l frequent (4-6 hours) ar El oonsmm (6-8 hours]:

 

 

hand/Min wuvk El l:l mm; a El walking driving
a overhead work ammo l: puth:/ pulling a compuler lam enlry
El mo mmuke hunk every minnm lmrn.
"om/Wm Wm a "mom", a bump" mm: a walkms onulng (warhead walk a Michal;
3 mm


a non ml:

emmrodnnmoorolwzelo duly5.12 1245 a 15-24 a om.
annoys: a: or; IF NO WDRKISAVAILABLE 

sums

"ush- a mu; 
mum" mm mm 5 ls Permagem and suuonam follow.

Pifienl WI .
a vamm d- .. "9 Permanonl rosldualx.
"Hmong" humus; .
w. MA 

mm. mm, whit: Worm.
um". "MM-known a 
Slgnamr: Mm: may. Mn "Mr If" 

"mell- Hammond Dim

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mess ommCam Phone: 510 535 2545 Urgent care

Inmmnal rmunes

39m Fame" mm. Sun: 131 Fax. 510 5u5.9237 .
omn'an Fvemonv. (AS4533 Empluyevservloes
mm bod". I "that:

  
   
     

WDKK HATUS 

  

 

 

 

EmnWeNimt: a $110 Bat 3 lb
magnum. .7 Mm:
mamds. 
mum smus
\nmaVV'siK Fallow--up mm a m; lmurv has been ruled nun-mduslnal a mum Only a Preventative 
symmoms hava. impmved as expenld pmved slowev man mum

 

.3 nm mm Sigmflunfly pmuued, worsened

nay?
WW). 7m Ago
Homer:

501' ma new: a Med: are munmion
a Rehnil' emu.

 

 

 

 

 

 

 

 

 

 

 

a 5mm;
a mm:
a imam, X-ny a MRI an memes a other now Pill: .
wann sums 
Damn!" has b1!" m.
mun nollmnillnm anew son mud-find 

("mummy/mm. suns a "We mnuw um. nullm. W,
KW 
:mna mum. hugelmx/ squamu :rawim; a rum>>. on: mud work on"
a "a mam" no repeuuvz wnsunanu wuvl
5 a xuenran/ wuvkrm'v 

2 seldom hours}

a occasional 12-: mm D, .
. consnanx (53 hours).
a nana/wm, Wm "we, sup Na em 14 5 hours] ar

bending
:1 overhead work a reaching

a 5mm; 0 snnamg a walking a driving
a "mug

a mm; a mmpuur/ diu enlvv
Dtafl'mmun break every mmutesvmn.

hand/mm mm -
Homer mm" was Dslindmg Uwalkmg navemead work a reaching

a remain of! work unzu

nm 
a esnmated numbernf week: until full dutyer:

EMPLOYEE L7 BE arr WORK ll N0 Mon/Hm WORK rs AVA ILA BLE

DISCNARGE sums
men: permanently precluded engaging in her/his usual new
:1 Patient will requile future medical rare.

pallan 1: went; conditlun is Pumanent and sxauonavy
no ppvmanem msabnny anticipated.

. Iepontolono .
Patlanl wm have Delmanenl residuals. 

"flying" Panenus amalifiedl
taxman/my Ewan. 
S, I 5 mm unau Mnaflyalpedury'
gnarure.

"n .7.
Funnfl/ Dale: