KAISER PERMANENTE

Northwest Reqion

TNTERSTATE MEDICAL OFFICE EAST

3550 N INTERSTATE AVENUE
Portland, OR 97227
(s03) 285-932L

CLINICIAN'S REPORT OF WORK ABILITY

Jim Waters
523 Sw 1-3th Ave Apt 707
Portland, OR 9720s

Date Examined z L2 / te / zOOA

Work Rel-ated? No
Diagnosis (impression) : Recurrent teft-sided stroke
Plan (treatment): Back on anticoagulation; rest Lo recover.
Time loss authorized L2/Le/oB through r/04/09
Rel-eased for regular work duties on 1/05/09
Remarks: none
'),1'i ,/
Clinician' s Signature : t *t',' I l.f
t lti/\ ,
.rr/ttLf /, t t
.{ / (
1,2/1,8/2008
To disclose this form to someone other than the patient, please
have the patient sign form OOO4 -1,756 "Authorization for Kaiser
Permanente to use/disclose protected heal-th information. ',
 KAISER PERMANENTE
Northwest Reqion

INTERSTATE MEDICAL OFFICE EAST

3550 N INTERSTATE AVENUE
Portland, OR 97227
(s03) 28s-e321-

CLINICIAN'S REPORT OF WORK ABILITY

Jim Waters
523 Sw 1-3th Ave Apt 707
Portland, OR 97205

Date Examined z L2/ ft /zOOe

Work Related? No
Diagnosis (impression) : Recurrent left-sided stroke
Plan (treatment): Back on anticoagulation; rest Lo recover.
Time loss authorized L2/LB/OB through L/04/09
Rel-eased for regular work duties on J_/05lO9
Remarks: none
Clinician' s Signature :
,fames ruf
1,2/LB/2008
To disclose this form t,o someone other than the patient, please
have the patient sign form OOO4 -1756 t'Authorization for Kaiser
Permanente to use/discl-ose protected heal-th information.'r
 KAISER PERMANENTE
Northwest Region

TNTERSTATE MEDTCAL OFFICE EAST

3550 N INTERSTATE AVENUE
Portland, OR 97227
(s03) 28s-9321,

CLTNICIANIS REPORT OF WORK ABILITY

Jim Waters
523 Sw l_3th Ave Apt 707
Portl_and, OR 92205

Date Examined z t2/:-8/zOOe

Work Related? No
Diagnosis (impression) : Recurrent left-sided stroke
Plan (treatment): Back on anticoagulatl-on; rest to recover.
Time loss aurhorized I2/IB/oB through L/04/09
Released for regular w-ork d.uties on t/OslOg
Remarks: none
Clinician' s Signature :
a2/rc/zooe
To di_sclose this form to someone other than the patient, please
have the patient sign form 0004 -1"756
Permanente to use/disclose "Authorization for Kaiser
protected health information.,l