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Hand / Wrist / Elbow / Shoulder restrictions Right Left In an 8 hour day patient may in hours none 1-2 2-4 Stand and Walk Bend and Squat Carry and Level Lift Bend and Lift 4-6 Both 6-8 none 1-2 2-4 4-6 6-8 Sit Drive Push / Pull Other Restrictions Any Restriction Given Apply to Home and Leisure Activities Estimated Return to Full Duty is / / If unable to return on full duty date patient should return to clinic Provider Name please print Clinic Name Provider Signature Clinic Address 6/08 INSTRU ...

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2008	4.8 Satisfied (62 Votes)

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