Functional Abilities Form - WSIB Early and Safe Return to Work

Specialty: Physician FUNCTIONAL ABILITIES FORM FOR PLANNING EARLY AND SAFE RETURN TO WORK Date of Assessment: 01 November 2024 Employee Name: John Doe Date of Birth: 15/03/1980 Occupation: Construction Worker (General Labourer) Employer: BuildCo Ltd. Date of Injury/Illness: 15/09/2024 Primary Diagnosis: Lumbar disc herniation, L4-L5, right-sided, with radiculopathy Prognosis for Full Recovery: Good, anticipated within 3-6 months with appropriate rehabilitation. Date of Most Recent Clinical Examination: 28/10/2024 Summary of Current Clinical Status: Mr. Doe presents with persistent lower back pain radiating down his right leg to the calf. Pain is exacerbated by prolonged standing, lifting, and bending. He reports numbness and tingling in the right L5 dermatome. Straight leg raise positive at 45 degrees on the right. Motor strength 4/5 in right ankle dorsiflexion. Reflexes are intact bilaterally. He is currently engaging in physiotherapy twice weekly. Summary of Functional Impairments: * Difficulty with prolonged sitting (greater than 30 minutes) and standing (greater than 20 minutes). * Impaired ability to lift more than 5 kg from the floor, or 10 kg from waist height. * Reduced ability to bend, twist, or squat. * Limited walking tolerance (approximately 200 meters without significant discomfort). * Difficulty climbing stairs or ladders. RECOMMENDED WORK RESTRICTIONS/MODIFICATIONS: Temporary Work Restrictions (Specify duration): For the next 4-6 weeks, with re-evaluation after this period. * Lifting: No lifting greater than 5 kg (occasional), 2 kg (frequent). * Carrying: No carrying greater than 5 kg (occasional), 2 kg (frequent). * Pushing/Pulling: Avoid heavy pushing/pulling requiring significant core engagement. * Standing: Limit prolonged standing to 20 minutes, with frequent opportunities for position change or sitting. * Sitting: Limit prolonged sitting to 30 minutes, with frequent opportunities for stretching or standing. * Walking: Limit walking to short distances (e.g., within a building), avoid uneven terrain. * Bending/Twisting/Squatting: Avoid repetitive or deep bending, twisting, or squatting. * Reaching: Avoid overhead reaching or reaching requiring significant trunk rotation. * Repetitive Hand/Arm Movements: No specific restrictions, but monitor for exacerbation. * Driving: Limited to short commutes (under 30 minutes) with breaks. * Other: Avoid vibrating tools or equipment. No climbing ladders or scaffolding. Recommended Graduated Return to Work Plan (if applicable): Phase 1 (Weeks 1-2): Modified duties, 4 hours/day, 3 days/week. Primarily desk-based tasks or light administrative work, with frequent breaks and self-monitoring for pain. No lifting, bending, or prolonged standing. Phase 2 (Weeks 3-4): Increase to 6 hours/day, 4 days/week. Introduction of very light tasks (e.g., sorting small items, light assembly without heavy lifting). Continue frequent breaks. Max lift 2 kg. Phase 3 (Weeks 5-6): Increase to 8 hours/day, 5 days/week. Gradual increase in light physical activity within the 5 kg lifting restriction. Continue to avoid repetitive bending/twisting. Expected Date of Full Duty Return (without restrictions): Approximately 15 February 2025 (subject to progress). Other Recommendations/Comments: Employee requires ergonomic assessment of their workstation if performing desk duties. Continued adherence to physiotherapy and home exercise program is crucial. Open communication between employee, employer, and healthcare provider is encouraged to facilitate a safe and effective return to work. Consideration for job modification such as a height-adjustable desk or anti-fatigue matting would be beneficial. Signature of Physician: Dr. Emily White License Number: 123456 Contact Information: 020 7946 0000