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SU)3,7ECT: F'r'aJ~2IL,Y MEUi"CAL LEAVE ACT {1~`} RAGE 9 6.Q2 <br />PAGE 1 ~? JF' 1 <br />w.. Will the pati~rrt require fo3low-rrp treatments, i.rr;:luding any tune <br />for recovery? _ __No _ _~Yes <br />asst i rnate treatment sc2ridu l.e, i f any, including the dtYtes cf any <br />scheduled appcint_ments and the time required foe. each appontnrenr:, <br />inclur.ing any recovery period: <br />Explain the car•P needed by the patient, a.nd why such care is <br />medically necessary: ,~__._ ~ -.._._ <br />Q . Will t.trc~ patient require care on an nt:ermi t tent or redus~ed <br />schtduie basal, inr_l>rdrng any t:ilrre £or° i-ecavez-y? __~_[dra _--Y''s <br />Esti!rate the hours the patient needs care ran an inter:°rnitt~~nr. <br />basis , i f any: _ harry { s 1 per day; ~-_. day:r par w:.ek <br />Er am tYrrcaugf! __,...__.~ _ <br />fsxplain the care need>;;d by the patient, and why suci~ care is <br />medically necessary: .. .. <br />7. 4vi31 tare cnnditian cause episodic flare-ups pe7-indicu3ly <br />preventing the patient. Pram participating in riax~mal. daily <br />activities? No 'Yes <br />Based upon the patient's medical history and. yraur knowleuye cif t:l':e <br />rnedical condition, estimate the frequerYC:y of flare-rrC>s and the <br />duxation cai: related incapacity f..hat tt!e patient. rrray have aver the <br />next ~> man!-:tts {e..g. 1. episode every 3 months lasting 1-2 days! <br />Frequency :... ._...t i mes p~ r` .~......._..week (s) _ ............... mint t!s { s ) <br />[)urat i on : _ ___ hours t5r --days { s) per epa sc~de <br />I,oc:s tine patient need cars during Chess flare-ups? -...... t3a __ ..-Yea <br />