AUTHORIZED HEALTHCARE PROFESSIONAL USE
Patient reference: __________ Assessment date: __________
This section records the clinician verified findings only.
Date(s) assessed: ___________________________________
Relevant attendance restriction, if assessed: _________
Recommended period / review date: ___________________
Necessary adjustments: ______________________________
Scope of information authorized for release: __________
Clinician / registration / contact: __________________
Signature / issue date: _____________________________
Blank form only. It is not evidence that an examination occurred.