Queensland Work Capacity Certificate Form

Work Capacity Certificate Form **Patient Details** Full Name: John Smith Date of Birth: 15/03/1980 Address: 123 Oak Avenue, London, SW1A 0AA Contact Number: 07700 900123 **Clinical Information** Diagnosis: Right Tibial Plateau Fracture (ICD-10: S82.121A) Date of Injury/Onset of Condition: 20/09/2024 Reason for incapacitation: Significant pain and inability to weight-bear on the right lower limb, requiring immobilisation. **Work Capacity Assessment** **Current Work Status:** [X] Unable to work at all [ ] Able to work with some limitations (see below) [ ] Able to work without limitations **Period of Incapacity:** Start Date: 20/09/2024 End Date: 15/12/2024 **Anticipated Return to Work Date:** 16/12/2024 **Work Restrictions/Limitations (if applicable):** **Nature of work restrictions (if applicable):** Patient is advised to avoid any weight-bearing activities on the right leg. No prolonged standing or walking. Requires a sedentary role with frequent breaks for elevation and pain management. Patient should not drive until cleared by the orthopaedic team. **Modifications required (if applicable):** Provision of an adjustable height desk, ergonomic chair, and access to a quiet space for rest breaks. Potential for phased return to work with reduced hours initially. **Prognosis:** Good, with expected full recovery following appropriate rehabilitation. Regular follow-up with orthopaedic surgeon and physiotherapist is essential. **Certifying Medical Practitioner Details** Full Name: Dr. Eleanor Vance Professional Title: Consultant Orthopaedic Surgeon Clinic/Hospital: St. Thomas' Hospital Contact Number: 020 7123 4567 Signature: (Electronic Signature: Dr. Eleanor Vance) Date of Issue: 1 November 2024