Family Medical Leave Act Questionaire

The questions below are designed to assist your physician in filling out your FMLA form. When answering these qeustions it is helpful for you to have your dates of treatment and diagnosis which can be obtained from your office or hospital discharge paperwork. Please answer these questions as completely and carefully as possible.

Patient Information

First Name Middle Name Last Name *

Birth Date (MM/DD/YYYY) *

Daytime Phone *

Address *

City *

State *

Zip Code *

Employer Name

Employer Contact Name

Job Title

Regular Work Schedule

What are your essential job functions

Policy Number (if applicable)

Is the cause of your disability an accident or illness? *

Yes

No

If accident or illness please explain

Have you ever experienced these symptoms before? *

yes

no

Is this work related? *

yes

no

Date symptoms first appeared * +

Date of first visit to your doctor for this problem * +

How long do you expect this condition to last? *

Date of last visit with your doctor for this problem * +

Anticipated frequency of future visits

weekly

monthly

other other

Date disability began * +

Date you returned or expect to return to work. Give estimate if unknown. * +

Are you unable to any of your job functions due to the condition? *

yes

no

Will you be incapacitated for a continuous period due to the condition? *

No

Yes. List Job functions you are unable to perform Yes. List Job functions you are unable to perform

Will you need to attend follow up appointments or work on a part-time or on a reduced schedule due to the condition? *

yes

no

Estimate the part-time or reduced hours needed in a day *

Estimate the part-time or reduced days needed in a week *

What is the estimated begin date for reduced work? * +

What is the estimated end date for reduced work? * +

What do you anticipate the schedule for your follow-up appointments to be? *

Do you expect to need to be treated at least twice yearly for this condition *

Yes

No

Do you expect episodic flare-ups of this condition? *

Yes

No

Will you need to be absent from work during any flare-ups *

No

Yes. Explain: Yes. Explain:

If so are the absences medically neccessary *

yes

no

Symptoms that prevent you from working. (check all that apply) *

What treatments are you currently receiving?(Check all that apply) *

Diagnosis (include numeric code if you have it. You can get this from your most recent "Patient Care Summary" from your last physician visit.) * 🛈

Hospitalization *

yes

no

If hospitalized, date of First admission. +

If hospitalized, date of 2nd admission. +

If hospitalized, date of 3rd admission. +

If hospitalized, date of discharge. +

Is the medical condition pregnancy? *

yes

no

If condition is pregnancy, expected delivery date +

Surgery? *

yes

no

If you had surgery, date of surgery or anticipated date of surgery +

If you had or are having surgery specify the type

Surgery or post surgery complication? *

yes

no

Physical limitations *

What job functions are you unable to perform? *

Was medication, other than over-the-counter medications prescribed? *

yes

no

Were you referred to other health care providers (like physical therapy or other doctors) to assist in the treatment of your condition? *

yes

no

What kind of treatment did you receive from the other provider(s)? *

How long are the limitations expected to continue? Pick a number and a interval *

First and Last Name of Physician *

Credential

Specialty *

Phone number *

Fax Number

Physician's Address *

By clicking the box I certify that I have read and agree to the HIPAA compliance statement *

I Agree

By clicking here I certify that the answers I provided to the above questions are complete and true to the best of my knowledge and belief. *

I agree

*

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