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Medical Leave · Visit Preparation

Medical Leave · Leave Visit Preparation

Before Your
Appointment

Please complete this before your appointment if possible. This form helps your medical provider understand your condition, how it is affecting work, and what paperwork may be needed. Brief answers are fine.

8–10Takes about 8–10 minutes.

ConfidentialFor clinical use only.

PrepareBring or upload your leave paperwork.

Important: Completing this form does not guarantee approval of leave, disability benefits, restrictions, or paperwork. Recommendations are based on your provider's clinical evaluation and available medical information.

When you finish, save as PDF and upload it to your patient portal at MyPremiseHealth.com or the My Premise Health app at least 48 hours before your appointment, when possible.

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1. Leave Preparation

Where You Are in the Process

Tell us what you know so far. It is okay if some details are still being worked out.

Have you started the leave or FMLA process with your employer or HR?

Yes No Unsure

Have you received leave paperwork from your employer, leave administrator, or insurer?

Yes, and I have uploaded it to my patient portal Yes, but I have not uploaded it yet No Unsure

What type of leave are you requesting?

Continuous leave — completely off work for a period of time Intermittent leave — occasional absences for a medical condition Reduced work schedule Combination / unsure

Requested first day off work

Expected return-to-work date, if known

When would you like intermittent or reduced-schedule leave to begin?

How often do you expect to need time away from work?

Example: 1–2 episodes per month, 1 day per episode; or 2 appointments per month lasting 2 hours each.

Current Medical Care

Who are you currently working with for this condition? (select all that apply)

Health Clinic medical provider Specialist Physical / occupational therapy Primary care provider outside Health Clinic Surgeon / procedural provider Other

Have you discussed leave with a treating medical provider?

Yes No Not yet

2. Medical Condition

What Is Happening Medically

Provide a brief overview of the condition, injury, surgery, or treatment related to your leave request.

What medical condition, illness, injury, surgery, or treatment is causing you to request leave?

Approximately when did this condition begin?

Has a healthcare provider evaluated or diagnosed this condition?

Who is currently treating you for this condition?

First visit for this condition

Most recent visit

Next scheduled visit

Current Symptoms

Which symptoms are affecting you currently? (select all that apply)

Pain Weakness Fatigue / low stamina Dizziness / lightheadedness Shortness of breath Nausea / vomiting Headaches / migraines Sleep disruption due to condition Reduced mobility Balance problems Swelling Numbness / tingling Limited range of motion Difficulty using arm / hand Difficulty using leg / foot Cognitive difficulty related to condition or treatment Medication side effects Other

Briefly describe your most significant symptoms and how severe they are.

3. Functioning at Work

How the Condition Affects Work

Focus on what has become difficult, limited, or unsafe because of the medical condition.

Which work activities are affected? (select all that apply)

Sitting for extended periods Standing Walking Walking on uneven surfaces Climbing stairs Squatting / crouching Kneeling / crawling Bending / stooping Reaching overhead Repetitive arm / hand movement Keyboarding / mousing Lifting Carrying Pushing / pulling Driving Operating equipment Speaking Hearing Vision-related tasks Maintaining stamina through the workday Working a full workday Working consecutive days Other

Most Important Work Limitations

List up to three work activities that are most affected right now.

Describe what happens when you try to perform these activities.

Example: “Standing longer than 15–20 minutes increases pain and swelling and I need to sit and elevate my leg.”

Physical Tolerance

Use your best estimate based on your current functioning. Your provider will make the medical determination about restrictions.

No difficulty

<15 min

15–30 min

30–60 min

>60 min

Sitting at one time

Standing at one time

Walking at one time

How much can you comfortably lift or carry right now?

Less than 10 lb 10–20 lb 21–50 lb More than 50 lb Unsure No limitation

Are there movements or activities your condition prevents or significantly limits?

4. Treatment & Leave Pattern

Treatment, Testing, and Flare-Ups

This helps your provider understand what treatment is occurring and whether intermittent absences may be medically necessary.

What treatment are you currently receiving? (select all that apply)

Prescription medication Physical therapy Occupational therapy Surgery / procedure Specialist care Home exercise / rehabilitation Medical equipment / assistive device Other

Have you had relevant testing or medical care for this condition? (select all that apply)

Laboratory testing X-ray MRI / CT / other imaging Procedure / surgery Emergency department visit Hospitalization Specialist evaluation Other

Briefly describe relevant treatment, testing, or results your provider should know about.

Hospitalization / Surgery

Have you been hospitalized for this condition?

If yes, dates

Have you had, or are you scheduled for, surgery or another procedure?

Date, if known

Procedure, if known

Expected recovery period, if a treating provider has given you one

Flare-Ups / Intermittent Absences

Does your condition cause episodes or flare-ups that may prevent you from working?

Yes No

Approximately how often?

How long does a typical episode last?

How much recovery time do you typically need before returning to work?

Do medical appointments or treatments also require time away from work?

Yes No

Approximate appointment frequency

Approximate time needed per appointment

5. Your Job

Work Demands & Final Details

A brief description of your normal job helps your provider connect medical limitations to actual work demands.

Job title

Typical work schedule

Briefly describe your usual job duties.

Does your job regularly require any of the following? (select all that apply)

Prolonged sitting Prolonged standing Walking Lifting / carrying Pushing / pulling Repetitive hand / arm use Keyboarding Driving Operating equipment Working at heights Other physical demands

What parts of your job are you currently unable to perform, or can only perform with significant difficulty?

Anything else you want your medical provider to know before your visit? Optional

Your name

Date completed

Important: This form helps your provider prepare for your visit but does not determine whether leave, disability, or work restrictions will be recommended. Your provider will make recommendations based on clinical evaluation, treatment information, medical findings, and available documentation.

What to do next

Save this completed form as a PDF using the button below.
Upload it to your patient portal at MyPremiseHealth.com or the My Premise Health app at least 48 hours before your appointment, when possible.
Upload or bring any leave, FMLA, disability, or employer paperwork that needs to be completed.

The Health Clinic at Fred Hutch | Confidential — for clinical use only | Completing this form does not guarantee approval of leave

Before YourAppointment

Where You Are in the Process

Current Medical Care

What Is Happening Medically

Current Symptoms

How the Condition Affects Work

Most Important Work Limitations

Physical Tolerance

Treatment, Testing, and Flare-Ups

Hospitalization / Surgery

Flare-Ups / Intermittent Absences

Work Demands & Final Details

Before Your
Appointment