Premise Health.

Supporting
Your Patient's
Leave Request

Clinical Input Form

For treating providers : return to The Health Clinic at Fred Hutch.
This form helps us understand how your patient's condition affects their ability to work and whether leave may be appropriate.

Your response is confidential and protected by applicable privacy laws.

Please answer each question completely and accurately.

Most providers complete this in about 5 minutes.

Return completed form to:

The Health Clinic at Fred Hutch
Fax: 206-667-2273 | Phone: 206-667-3000
Arnold Building, Level E | ourcampusclinic.org

The Health Clinic | Operated by Premise Health | Fred Hutch Campus

Fax: 206-667-2273 | 206-667-3000

1. About You

Provider Information

Your name and credentials

Best contact for follow-up

Your specialty / practice type

Date of this response

How long have you been treating this patient for this condition?

2. What Are You Seeing?

Diagnosis

Primary diagnosis

ICD-10 code

Secondary diagnosis (if applicable)

ICD-10 code

Clinical Narrative

In your own words, what brought this patient to you and what are you observing clinically? A few sentences is plenty

Approximate date symptoms began

Date restrictions first became clinically appropriate

History

Is this condition related to the patient's employment?

Yes No Unclear

Has the patient had a similar episode before?

Yes No

3. Current Treatment

Treatment Details

What treatment are you providing and how often are you seeing this patient?

Current medications (name, dose, frequency) : leave blank if none:

Is the patient receiving or being referred to any of the following?

No : not currently Partial hospitalization (PHP) Intensive outpatient (IOP) Inpatient Other specialty care

4. How Is This Affecting Their Work?

Rate your patient's current ability in each area. These ratings directly support the leave paperwork.

	1 Unable	2 Markedly limited	3 Somewhat limited	4 No difficulty
Maintaining attention and concentrationStaying focused without losing place on tasks
Performing at a consistent paceSustained productivity across a shift
Comprehending and completing daily tasksGrasping responsibilities and following through
Multi-taskingManaging multiple priorities simultaneously
Communicating effectivelyGetting point across clearly in conversation
Regulating emotions at workKeeping emotional responses appropriate
Following directions and instructionsActing on guidance from supervisors accurately
Interacting with colleaguesWorking cooperatively without friction
Making decisions and working independentlyFunctioning without constant support

Activities of Daily Work

	Good	Fair	Poor / None
Follow work rulesAdherence to workplace policies
Relate to co-workers and supervisorsWorking cooperatively with colleagues
Perform complex or varied tasksTasks requiring flexibility and judgment
Deal with work stressesManaging demands, deadlines and pressure
Demonstrate reliabilityConsistent attendance and dependability
Behave in an emotionally stable mannerMaintaining composure at work

Which 1-3 areas are affecting your patient's work the most right now? Describe in your own words

5. Your Recommendation

Type of Leave

Continuous leave (single period out of work)

From:

To (estimated):

Intermittent leave (episodic flare-ups)

Frequency (e.g. 2x per week):

Duration per episode (e.g. 1-2 days):

Reduced work schedule

Hours per day:

Days per week:

Estimated full-duty return-to-work date

Date to re-evaluate if still on leave

Accommodations

Can your patient return to work with accommodations before full duty?

Yes No Possibly

If yes, describe accommodations that would support return to work:

Next steps

1
Your patient shares this form with you. They should have given you this link or a printed copy to complete before or during their appointment.
2
Complete all sections above based on your clinical knowledge of this patient. Brief answers are fine.
3
Save as PDF using the button below, then return the completed PDF to your patient.
4
Patient uploads the PDF via MyPremiseHealth.com or the My Premise Health app prior to their appointment at The Health Clinic.

Questions? Call The Health Clinic: 206-667-3000 | Fax: 206-667-2273

SupportingYour Patient'sLeave Request

Supporting
Your Patient's
Leave Request