Free Sample Doctor Fit Note Template
Sample Doctor Fit Note
Date: September 12, 2080
Patient Name: Jasen Gaylord
DOB: July 19, 1952
Patient ID: 55678
Provider: Dr. [Your Name]
Specialty: Occupational Medicine
Facility: [Your Company Name]
Contact: [Your Company Email] | [Your Company Number]
Reason for Note: Return to Work Fitness
Summary of Assessment:
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Diagnosis: Jasen Gaylord was previously treated for a shoulder injury sustained on September 1, 2080. After undergoing appropriate treatment and rehabilitation, including physical therapy and medication, he has demonstrated significant improvement.
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Current Condition: Jasen’s shoulder has healed adequately, and he has regained full range of motion and strength. There are no longer any restrictions on his ability to perform work-related tasks.
Fit for Work:
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Effective Date: September 12, 2080
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Capacity: Jasen is fit to return to work full-time. He is cleared to resume all normal work activities without any restrictions.
Additional Recommendations:
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Workplace Modifications: Jasen may benefit from a brief adjustment period to gradually resume full physical activity. If any discomfort or issues arise, he should consult with his healthcare provider.
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Follow-Up: No further follow-up appointments are required unless new symptoms develop.
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Notes: Jasen has been advised to continue any prescribed exercises and maintain ergonomic practices to prevent future injuries.
Prepared by:
Dr. [Your Name]
