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50 lbs lbs 20 lbs 10 lbs Worker progress As expected / better than expected. Slower than expected. Address in chart notes Current rehab PT OT Home exercise Other Surgery Comments Not Indicated Possible Planned F245-067-000 Activity Prescription Form 1069M APF version 4 Acute pain or Chronic pain Any permanent partial impairment Yes No Possibly If you are qualified please rate impairment for your patient. ACTIVITY PRESCRIPTION FORM APF Sta.

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