REQUIRED information in case pages get separated: Claimant First Name Middle Name Last Name Claim Number How many hours in a workday can your patient lift or carry: Hours (0 to 8) Continuously Intermittently Breaks Frequency Duration Up to 10 lbs. 11 to 20 lbs. 21 to 50 lbs. 51 to 100 lbs. Over 100 lbs. How many hours in a workday can your patient push or pull: Hours (0 to 8) Continuously Intermittently Breaks Frequency Duration Up to 10 lbs. 11 to 20 lbs. 21 to 50 lbs. 51 to 100 lbs. Over 100 lbs. Can your patient operate a motor vehicle? Yes No Is your patient at maximum medical improvement? Yes No Please make any additional notes. About Your Patient's Prognosis Have you advised your patient when they can return to work? Yes (Check all that apply) To regular occupation. On date (mm/dd/yyyy) Full-time Part-time Modified duty To any other occupation. On date (mm/dd/yyyy) Full-time Part-time Modified duty No (Please explain) List any restrictions to work or activity. (Please be as specific as possible.) APS-STDLTD-5320 (06/20) Page 4 of 7