Get Ptot Work Conditioning Questionnaire For Faxing Reviews W Request Form - Qualishealth

The PTOT Work Conditioning Questionnaire is a vital document used for assessing a person's readiness for work after rehabilitation therapy. This guide will assist you in accurately completing the form online, ensuring all necessary information is provided for efficient processing.

Follow the steps to fill out the PTOT Work Conditioning Questionnaire online.

1. Press the ‘Get Form’ button to access the document and open it in your chosen editing tool.
2. Enter the date of the initial work conditioning evaluation in the appropriate field.
3. Indicate the number of scheduled visits from the initial evaluation through the expiration of the current authorization period.
4. Record the number of completed visits from the initial evaluation through to the expiration of the current authorization period.
5. If therapy was provided before the evaluation date, select 'Yes' and fill in the number of visits; otherwise, select 'No'.
6. Input the date of the current therapy prescription for the patient.
7. Assess the patient's rehabilitation potential towards returning to work by selecting 'Good', 'Fair', or 'Poor'.
8. Indicate whether the patient is currently working in any capacity by selecting 'Yes', 'No', or 'Unknown'.
9. Describe the return to work goal, specifically the job title, or state the goal for the physical capacity level if no specific job title is available.
10. Check all applicable options to describe the patient’s therapy program.
11. Detail any neuromuscular, physical, or functional deficits that could interfere with returning to work and note any relevant pain levels.
12. If the patient is in work conditioning, describe any unresolved barriers to achieving their goals, or state 'none' if there are no barriers.
13. Confirm whether there is documented progress towards measurable return to work goals with 'Yes' or 'No', and provide the patient’s progress in lifting and carrying abilities over the specified weeks.
14. Fill in the current estimated date of discharge.
15. Indicate whether a pain program is anticipated by selecting 'Yes', 'No', or 'Unknown'.
16. Select whether work hardening is anticipated, choosing 'Yes', 'No', or 'Unknown'.
17. Enter the patient's name and claim number in the designated fields.
18. Review all provided information for accuracy and clarity.
19. Once all fields are completed, save your changes, and consider downloading, printing, or sharing the form as needed.

Complete your PTOT Work Conditioning Questionnaire online for streamlined processing.