PART A: MEDICAL FACTS
1. Approximate date condition commenced: ______________________________________________________
Probable duration of condition: ______________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
___No ___Yes. If so, dates of admission:
________________________________________________________________________________________
Date(s) you treated the patient for condition:
________________________________________________________________________________________
Will the patient need to have treatment visits at least twice per year due to the condition? ___No ___ Yes.
Was medication, other than over-the-counter medication, prescribed? ___No ___Yes.
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
____No ____Yes. If so, state the nature of such treatments and expected duration of treatment:
________________________________________________________________________________________
2. Is the medical condition pregnancy? ___No ___Yes. If so, expected delivery date: ____________________
3. Use the information provided by the employer in Section I to answer this question. I f the employer fails to
provide a list of the employee’s essential functions or a job description, answer these questions based upon
the employee’s own description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition: ____ No ____ Yes.
If so, identify the job functions the employee is unable to perform:
________________________________________________________________________________________
4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave
(such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use
of specialized equipment):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Page 2
CONTINUED ON NEXT PAGE
Form WH-380-E Revised May 2015