Sharon Klein

 
 <<Back to Review>>180298-26-HYPERLINK- Hyperlink-Page 
 205 
 Work Wellness 
 July 25, 2018 
 1521 Colorado Ave Ste 152 Turlock, CA 95282 
 Page 1 
 (252) 252-3523 Fax: (529) 526-3520 
 Patient Information 
 For : Sharon Klein
 Work Status Report 
 Date of Report: 12/12/2023
 Time In: 5:4 AM 
 Time Out: 10:06 AM 
 Injury Date: 02/12/2019 
 Diagnosis: 
 Schizophrenia (ICD-719.47) (ICD10-M25.571)  
 Pursuant to California Civil Code section 53.31 and Labor Code 3762. medical information regarding employee'92 worker'92 compensation injuries is 
 deemed confidential medical information and may not be disclosed except in very limited circumstances.
 Instructions: - seated work only 
 ELECTRONICALLY SIGNED BY: Jennifer S Wong DO (17/08/2015) 
 Patient Signature: 
 Ed Foster 
 Date: 08/03/2024 
 005205 
 pr tae 0525
