Treatment Status - Gilery Ogando
DATE OF ACCIDENT: ______ /______ /______
FILE NO.: ________
NAME, ADDRESS AND TELEPHONE NUMBER OF DOCTOR YOU ARE CURRENTLY TREATING WITH:
HOW OFTEN ARE YOU RECEIVING PHYSICAL THERAPY?
ARE YOU TREATING WITH ANY SPECIALIST?
IF SO, LIST NAME, ADDRESS AND TELEPHONE NUMBER OF SPECIALIST:
DO YOU HAVE ANY TINGLING, NUMBNESS OR FALLING ASLEEP SENSATIONS IN YOUR ARMS OR LEGS?
ARE YOU SATISFIED WITH THE TREATMENT YOU ARE RECEIVING FROM YOUR DOCTOR?
HAVE YOU COMPLETED YOUR TREATMENT?
IF SO, WHEN WHERE YOU FORMALLY DISCHARGED?
DID YOU MISS TIME FROM WORK?
IF SO, LIST DATES YOU MISSED FROM WORK
Leave this empty:
Your legal name
If you have questions about the contents of this document, you can email the document owner.
Document Name: Treatment Status - Gilery Ogando
Agree & Sign