Use this as a private worksheet
Track every change in medical work restrictions and compare it with actual job duties. This is not an official agency or court form.
Restriction log
- ☐ Date: ______________________________
- ☐ Provider: ______________________________
- ☐ Restriction: ______________________________
- ☐ Duration: ______________________________
- ☐ Next review: ______________________________
Job comparison
- ☐ Job task: ______________________________
- ☐ Physical demand: ______________________________
- ☐ Allowed?: ______________________________
- ☐ Question for provider/employer: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.