Referral form for Workwell FCE
1. Referrer
Referrer Phone Number
Referrer email address
Clients Primary Physician
Physician Phone Number
Physicians email address
Client Name
Client DOB
Client Phone Number
Date of Injury
/
Month
/
Day
Year
Date
3. Referring Diagnosis
3a. Was there surgery related to this injury?
Yes
No
Describe
4. Other medical history/surgery
Yes
No
Describe
4a. Other medical problems
4b. Is there a history of high blood pressure?
Yes
No
4c.Has a doctor ever said the client is limited from activity due to a history of heart problems?
Yes
No
4d. Is there a history of chest pain (with or without physical activity)?
Yes
No
Reason for FCE
5a. Is the FCE for return to work testing?
Determine ability to return to previous job
Determine ability to return to any job
Recommendations for ergonomic changes or accommodation
“Fit for duty” testing
Recommendations to assist with return to work
5b. Is the FCE to determine the clients abilities?
Determine physical abilities - 1 day testing (unless additional medical problems)
Determine client's abilities before starting rehabilitation program
Vocational Rehabilitation placement
5c. Is the FCE for case closure or disability?
Medical legal testing - 2 day testing recommended
Disability evaluation - 2 day testing recommended
6. Other
For office use only
Date therapist reviewed referral
-
Month
-
Day
Year
Date
Job description received
Yes
No
Pending
Date expecting to receive job description
-
Month
-
Day
Year
Date
Therapist recommendations
Occupational Therapist
Date
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: