Doctor’s Injury Certification Template

[Clinic / Practice Name]
[Street Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Fax: [Fax Number]
Email: [Email Address]

1. Patient Identification

Patient Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]

Patient ID / Chart Number (if applicable): [ID Number]

Home Address:
[Street Address]
[City, State/Province, ZIP/Postal Code]

Phone Number: [Phone Number]
Email Address: [Email Address]

2. Evaluating Provider Information

Provider Full Name: [Name]
Professional Title and Credentials: [e.g., MD, DO, NP, PA]
Specialty: [e.g., Emergency Medicine, Orthopedics, Family Medicine]

License Number: [Number]
Licensing State/Province: [State/Province]

Practice / Facility Name: [Name]
Address: [Street Address, City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Fax: [Fax Number]

3. Examination Details

Date of Examination: [MM/DD/YYYY]
Time of Examination (if relevant): [HH:MM a.m./p.m.]

Location of Examination: [Clinic / Hospital / Emergency Department / Other]

Evaluation Type:

• Initial Evaluation

• Follow-Up Evaluation

This certification is being completed for (check all that apply):

• Work / Employer

• School / University

• Insurance

• Legal / Court

• Other: [Describe]

4. Injury Incident Summary (As Reported by Patient)

Date of Injury: [MM/DD/YYYY]
Approximate Time of Injury: [HH:MM a.m./p.m., if known]

Location of Injury: [Workplace, home, street, school, sports facility, etc.]

Brief Description of Incident (patient’s report):
[Free-text narrative, e.g., “Patient reports that on [date], while [activity], they…”]

Note: The above description is based on the patient’s statements and is not an independent investigation of the incident.

5. Diagnosis and Injured Body Area(s)

Primary Injury Diagnosis:
[Diagnosis name and, if desired, ICD-10 code]

Additional Injury Diagnoses (if applicable):
[Diagnosis 2]
[Diagnosis 3]

Body Part(s) Affected:

• [e.g., “Left ankle,” “Right shoulder,” “Lumbar spine,” “Head,” etc.]

Injury Type (check or describe):

• Contusion / Bruise

• Laceration / Cut

• Sprain / Strain

• Fracture / Suspected Fracture

• Concussion / Head Injury

• Soft Tissue Injury

• Other: [Describe]

6. Clinical Findings and Tests

Physical Examination Findings (summary):
[Brief description, e.g., “Swelling and tenderness over…,” “Reduced range of motion…,” “Neurological exam normal/abnormal,” etc.]

Imaging / Tests Performed (if any):

• X-ray – Date: [Date] – Results: [Summary]

• CT Scan – Date: [Date] – Results: [Summary]

• MRI – Date: [Date] – Results: [Summary]

• Ultrasound – Date: [Date] – Results: [Summary]

• Laboratory Tests – [Type and brief results]

• Other: [Describe]

Summary of Objective Findings:
[Short, clear statement summarizing key findings relevant to the injury.]

7. Treatment Provided and Current Plan

Treatment Provided to Date (check or describe):

• Wound care / suturing / dressing

• Splint / cast / brace applied

• Pain management (medication)

• Anti-inflammatory medication

• Physical therapy referral

• Specialist referral (e.g., orthopedic, neurology)

• Hospital admission

• Other: [Describe]

Current Treatment Plan and Recommendations:
[Brief description, e.g., “Continue wearing brace,” “Begin physical therapy 2 times per week,” “Follow-up visit in 2 weeks,” etc.]

8. Functional Limitations and Activity Restrictions

Based on my clinical evaluation as of [Date], the patient has the following limitations and restrictions:

Work / School Status:

• May work / attend school with no restrictions as of [Date].

• May work / attend school with restrictions as outlined below.

• Temporarily unable to work / attend school from [Start Date] to [Estimated End Date].

• Unable to determine work/school capacity at this time; further evaluation needed.

Activity Restrictions (check all that apply and specify if needed):

• No lifting over [] lbs / [] kg.

• No prolonged standing or walking (limit to [___] minutes at a time).

• No running, jumping, or high-impact activities.

• No bending, twisting, or heavy pushing/pulling.

• No climbing ladders or working at heights.

• No driving or operating heavy machinery until [Date] or until cleared.

• Seated work only, with the ability to change positions as needed.

• Limited use of [right/left] arm / leg.

• Other restrictions: [Describe].

Expected Duration of Restrictions (subject to change with recovery):

• Less than 1 week

• 1–4 weeks

• 4–8 weeks

• More than 8 weeks

• To be determined at next follow-up

9. Prognosis

Overall Prognosis for Recovery from This Injury:

• Good (full recovery expected)

• Fair (recovery expected, may have some residual symptoms)

• Guarded (uncertain outcome; may have ongoing limitations)

• Poor (significant long-term or permanent limitations likely)

Comments on Expected Recovery:
[Brief narrative about anticipated improvement, need for ongoing care, or potential long-term effects.]

10. Additional Comments (Optional)

[Space for the provider to add any clarifying information regarding the injury, limitations, or special considerations. Avoid legal opinions or statements about fault.]

11. Provider Certification

I, [Provider Full Name], certify that I am a licensed healthcare provider and that the above information is accurate to the best of my knowledge, based on my examination of the patient and available medical records as of the date of this certification.

This certification is intended to describe the patient’s medical condition, treatment, and functional limitations. It is not a determination of legal liability or entitlement to benefits. Decisions regarding work status, accommodations, benefits, and legal issues are made by the appropriate employer, agency, insurer, or authority.

Provider Signature: _______________________________
Printed Name: [Provider Full Name, Credentials]
Date: [MM/DD/YYYY]

Optional Stamp or Seal:
[Space for provider or clinic stamp]