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aUI3J~:CT: )"AMILY 1"~EUICAL LEAVE ACT (F} PAGE 3 6. U2 <br />PAGE 1 `7 U F 19 <br />SVas rneclica*.: ion, o;.her i.han over-the-counter med:icatic~r~, <br />prescribed? No Yes <br />Will the patient used to ha~de treatment visits at 1Last twice pex° <br />year due r;o ~W he condi t ior,? Na Yes <br />Was the patient referred +_c other health care provider(s) for <br />evaluation ar treartment te.~•, physical therapist)? _ No <br />__Yes if so, state the nature of sue}-i tt'eatn;er.ts and expected <br />duration aC treatment: <br />is tltc cn~:dical condition re Wane '~ No Yes . t l= sic., <br />expected delivery date: <br />3. Des:_ribe other relevant medical facts, if any, related to tf:e <br />condition far which. the patient. needs care (suc2r rnedical i~acts may <br />include symptoms, diagnasis, ar any regimen of cc}nt.inuir~y <br />treatment as the use of speci.ali~ed equipment: <br />1?AK'1' B: AM~'UiJ'I' OF CARE NEEDED: When r~nswe2ing these questions, keep <br />in mind that your patient's need for care tay the employee seekinc3 <br />leave may include asststarrce with basic medical, hygetxic, <br />nutri ti onai , saLety or transpox~tat ion needs, or the px'a~•; i:~ i can of <br />physica ox~ psychological care: <br />4. UJi.li the patienC be incaparit«ted f:ar a siryle con"i_n+.ious period <br />oL" time, including any time for txeatmetZt and rCCr~very? _ Nc <br />__Yos TJstimat.:e the beginc'riny and. ending dates for the pex'iod r>i <br />incapacity: <br />1)ttri.ng this time, will the patient need care? iVo Yes <br />Exiilain the care n~~e~ierl by the iaatient and wl~y such care is <br />n1C:C71Caly tlt-'Ct'SSd1y: __....._ <br />