Do not smoke. Avoxl secondhand snvoke
ixereise regukarly. Ask your doctor adout a cardiac rehab program.
This indornitkn is not inteinled to replace advice given to you by your health care provider. Make sure you
disess any questons you lave witlh your lcalth care provider.
eunent Noleaned 00/18/2013 Docunont Revised 09/11/2019 Docurment Review ed: 02/01/2019
hever hter active atient Education
2020hevler nc
HOSPITAL STAY NOTE
was
MR 11IOMPSON RICKY LYNN
treated at ledell Menorial I lospital from 08/17/20-08/20/20
Injury
or
illness
was:
Work-relted.
Not work-rekited.
Undetermined if'work-rekated.
Heath care provider nmame (printed):
SMITHA PASULA
MD
leath care provider (signature):
Date:
pasula
08/20/20
How to use this form
Show this Return to Work statement to your supervisor at work as soon as possible. Your eployer should
be aware of your condition and may be able to help with the necessary work activity restrictions.
Contact your health care provikder if
You wish to retun to work sooner than the date that is listed above.
You have problems that make it dificult for you to return at that time.
Ihis inforntion is not intended to replace advice given to you by your health care provider. Make sure you
diseuss any questions you have with your health care provider.
Docunent Released 12/18/2006 Document Revised: 12/13/2018 Document Review ed: 12/13/2018
Elsevier Interactive Pattent Education 2020 Elsevier nc.
aspirin (oral)
(ASpir in)
Person Full Nane 114OMPSON, RKCKY LYNN
Date of Birth 10/23/1964
8 of 23
MRN (Encounter Alias) 220062