Return To Work Evaluation

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Date: [Insert date]

To:  
[Recipient Name or “To whom it may concern”]  
[Employer or Institution Name]  
[Address Line 1]  
[Address Line 2]

Re: Return‐to‐Work Fitness Evaluation for [Patient Name, DOB: MM/DD/YYYY]

Patient Identification:  
- Name: [Patient Name]  
- Date of Birth: [MM/DD/YYYY]  
- Employer: [Employer Name]  
- Job Title: [Patient’s Position]

Introduction:  
[Insert a brief statement identifying yourself, your professional role, the reason for the letter, and the context of the patient’s care.]

Medical History:  
[Outline a chronological timeline of the patient's relevant medical history and treatment course. One paragraph per each medical issue. At the end, include any restrictions or accommodations that were in place.]

Fitness Statement:  
[Structure into a clear, formal paragraph:]  
“The above‐named patient has been under my care for [duration]. Based on clinical evaluation, treatment response, and any relevant testing, the patient is now medically cleared to resume full duties without restrictions.”  

(If partial duties are still recommended, state specifics here.)

Recommendations:  
(hyphenated list)  
- [List any temporary accommodations or phased return measures, if applicable]  
- [e.g., “Begin with 4‐hour workdays for the first week”]  
- [e.g., “Avoid prolonged standing/weight lifting over X pounds for 2 weeks”]

Conclusion:  
[Reiterate the patient’s fitness for work, offer to discuss further, and provide your contact details for any questions.]

Sincerely,

[Signature Line]

- [Your Name], [Degrees/Credentials]  
- [Title and Department]  
- [Institution or Practice Name]  
- Phone: [##########]  
- Email: [[email protected]]