Circumference (in cm) ……………….. ………………. b) of the forearm (largest dimension)? Light Light c) of the muscles of the hand? Moderate Moderate Severe Severe Are there sensory disturbances? If YES, please state: NO YES 18 In which region? NO YES If YES, please state: In your assessment, is there reduced grip Right Left 19 strength? Light Light Moderate Moderate Severe Severe NO YES If YES, please state: Are there circulatory or trophic Which? 20 disturbances? Any comments? 21 Date of examination …………………………………………………………………………….. 22 (day/mth/year) Any relevant discharge letters and examination results etc. may be enclosed The medical information and assessments in this certificate are closely associated with the purpose of the certificate. Unless otherwise stated, I accept that the company may provide the patient or his/her representative with a copy of the certificate. This certificate has been completed by me in accordance with the existing The certificate is sent in a closed envelope marked "Attest" to: medical records, my knowledge of the patient, my questions to the patient and my examination of the patient: ………………….. ……………………………………………… Date Physician’s signature Exact address (stamp): Unless otherwise agreed prior to the request to the physician for completion of this certificate, the physician will receive payment upon submission of invoice in accordance with the of business. 04.05.44.04 physician’s terms
b) of the forearm (largest dimension)? c) of the muscles of the hand? Circumference (in cm) ……………….. ………………. Light Light Moderate Moderate Severe Severe 18 Are there sensory disturbances? NO YES If YES, please state: In which region? 19 In your assessment, is there reduced grip strength? NO YES If YES, please state: Right Left Light Light Moderate Moderate Severe Severe 20 Are there circulatory or trophic disturbances? NO YES If YES, please state: Which? 21 Any comments? 22 Date of examination …………………………………………………………………………….. (day/mth/year) Any relevant discharge letters and examination results etc. may be enclosed The medical information and assessments in this certificate are closely associated with the purpose of the certificate. Unless otherwise stated, I accept that the company may provide the patient or his/her representative with a copy of the certificate. This certificate has been completed by me in accordance with the existing medical records, my knowledge of the patient, my questions to the patient and my examination of the patient: ………………….. ……………………………………………… Date Physician’s signature Exact address (stamp): The certificate is sent in a closed envelope marked "Attest" to: Unless otherwise agreed prior to the request to the physician for completion of this certificate, the physician will receive payment upon submission of invoice in accordance with the physician’s terms of business. 04.05.44.04
fp-440-funktionsattest-underarm-og-haandled-pr-1-oktober-2016-engelsk.docx