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Encounter Addendum Notes

WORK STATUS REPORT

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Health Works

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Dale Generated: 12-19-2016 11:47:51

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NAME: Last: LEON

First: VICTORIA

Date of Exam: 12-19-2016 Case#: 083161915

Occupation: SORTER

DOB: 07-28-1980

DOI: 06-25-2014 09:00

Claim#:

Employer: _WASTE

Contact:_LAUR!', BARNETT

Tel.: (510)566-2784

Fax: (855)280-1567

Tet: (866)45e-8402

Fax:

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MANAGEMENT/ALAMEDA COUNTY

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Claims Administrator: GALLAGHER BASSETT

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Bilateral sacroiliitis (M46.1)

:,

DIAGNOSES

TREATMENT
Diagnostic Tests: Radiology: . Radiology tests were ordered. All radiology studies sent to Radiologist for review and confirmation.

1.,

Physical Therapy

( ) Start ( ) Continue ( ) Renew

( ) Umes I week for

( )weeks

( ) Cancel ( ) Pending

Chiropractic Therapy

( ) Start ( ) Continue ( ) Renew

( ) times I week for

( )weel<s

( ) Cancel ( ) Pending

Oceupatlonal Therapy

( ) Start ( ) Continue ( ) Renew

( ) times I week for

( )weeks

( ) Cancel ( ) Pending

Acupuncture

( ) Start ( ) Continue ( ) Renew

()#of visits

Ergonomic Evaluation

() Start

( ) Cancel ( ) Pending
Other: ()

Medications:

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WORK STATUS
This is not a first aid claim, Patient is advised to return to work without restrictions. Expected Maximum Medical
Improvement (MMI) date 12-19-2016.

Work Restrictions:
Discussed case with Laura Barnett.

DISCHARGE STATUS

(If applicable)

( X) NON-INDUSTRIAL. Patient Instructed to see private physician at own expense,
TREATING PROVIDER
Name: Katherine P,. Uphoff,PA.

Lie.#: PA20734

Specialty: Occupational Medicine

Date of El\am: 12•19-2016

Signature (Original)

NEXT APPOINTMENT
Next Appointment with on .
Executed at: US HealthWorks 13939 East 14th Street, San Leandro CA 94578 - 2613 Ph:510 343-8300

Page 1, VICTORJA LEON, Case# 0831 61915, Date of service 12-19-2016