Premise Health.The Health Clinic at Fred Hutch
Return to Work · Visit Preparation
Return to Work · Visit Preparation

Before Your
Return-to-Work Visit

Please complete this before your appointment if possible. This short form helps your medical provider review your planned return date, current work tolerance, and any physical restrictions that may still need to be considered.

2–4Takes about 2–4 minutes.
FocusedReturn date, hours, and restrictions.
PrepareUpload your Return-to-Work form.
Important: Your responses are for visit preparation only. Your medical provider will determine whether you are medically able to return to work and whether any restrictions are appropriate.

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

0% complete
1. Return Plan

Your Planned Return

Tell us when your absence began and when you are hoping to return.

Do you have a Return-to-Work form that needs to be completed by your provider?
2. Current Recovery

How You Are Doing Now

Keep this brief and focus on symptoms that still affect your ability to work.

Compared with when your leave began, how are you doing overall?
3. Work Hours

Can You Tolerate Your Normal Schedule?

Do you currently feel able to work your usual number of hours and days?
4. Physical Restrictions

Current Activity Tolerance

Based on how you are functioning now, select the option that best describes each activity. This is for visit preparation only. Your medical provider will determine the final restrictions, if any.

Activity
No
Restrictions
Restricted
25% of the time
Restricted
50% of the time
Restricted
75% of the time
Restricted
100% of the time
Sitting
Standing / Walking
Squatting / Crouching
Kneeling / Crawling
Bending / Stooping
Walking on Uneven Surfaces
Reaching (Overhead Extension)
Repetitive Motion
Lifts / Carries / Transfers (Push / Pull)
1–10 lbs.
11–20 lbs.
21–50 lbs.
>51 lbs.
Talking
Hearing
Keyboarding / Mousing
Vision: Near / Far
Vision: Depth / Color
Smell

If you are unsure how to rate an activity, leave it blank and discuss it with your provider.

5. Finish

Final Details

Reminder: Your provider will make the final determination about your return-to-work date, work hours, and any medical restrictions.
What to do next
  1. Save this completed form as a PDF.
  2. Upload it to your patient portal at MyPremiseHealth.com or the My Premise Health app before your appointment.
  3. Upload or bring the Return-to-Work form your medical provider needs to complete.
The Health Clinic at Fred Hutch  |  Confidential — for clinical use only  |  Completing this form does not determine medical clearance