Activity recommendations - Work

Patient____________________________ Date:____________


__Unable to return to work until further notice

Unable to return to work until: ________

Patient must attend hand therapy _________________

__Unable to work until after next office visit


Return to work on _________ with these restrictions:

No use of __right __left __either hand

Limited use of __right __left __both hands as noted below: __Frequent __Infrequent __None

Pushing __Frequent __Infrequent __None

Pulling __Frequent __Infrequent __None

Two handed lifting __Frequent __Infrequent __None

Reaching overhead __Frequent __Infrequent __None

Climbing __Frequent __Infrequent __None

Repetitive lifting __Frequent __Infrequent __None

Writing __Frequent __Infrequent __None

Fine manipulation __Frequent __Infrequent __None

Apply strong torque (turning force) __Frequent __Infrequent __None

Lift as much as _____ pounds

Lift more than _____ pounds

Temperatures less than 60 degrees F __Frequent __Infrequent __None

Exposure of hands to liquids __Frequent __Infrequent __None

Exposure to solvents or chemicals __Frequent __Infrequent __None

Heavy soilage of hands __Frequent __Infrequent __None

Working with rapidly moving machinery __Frequent __Infrequent __None

Working with vibrating tools __Frequent __Infrequent __None


__Splint must be worn __Bandage must be worn

10 - 30 second break for stretching exercises every _______minutes.

___If work is not available within these restrictions, then patient is unable to work

__Work restrictions effective until further notice

Work restrictions effective until:______________

Return to work on _________ with no restrictions