Billy Williams

 Springfield Regional
 6381 Phillips Street
Jessicaborough, AR 06933
 Workers' Compensation Medical Status Questionnaire 
 Patient Name: Billy Williams
 Today's date: 2014/07/04
 Patient ID #: 0452351 
 doi: 2020/07/03
 Employer: FOOD LION 
 Carrier: RETAIL BUSINESS 
 SERVICES 
 Treating physician: Dr Christopher Young 
 IC file: 2022224556 
 1. Diagnosis: Gastric Ulcer
 2. Treatment plan: WCP, NAPROXEN, ROBAXIN 
 3. Prescribed medications for the injury or condition that would impair ability or judgement needed to 
 perform certain jobs: 
 Lifting: 52LB MAX 
 Pushing/pulling: INFREQUENT 
 Bending/stooping: INFREQUENT 
 Kneeling, squatting: INFREQUENT 
 Twisting: INFREQUENT 
 Use of extremities: 
 Standing: 
 Walking: 
 Sitting: 
 Repetitive motions: 
 Driving: 
 Vibrations: 
 Climbing: 
 Splints/crutches/bandages: 
 Other restrictions: 
 7. If patient has reached maximum medical improvement (MMI), what is the permanent impairment 
 for the injury or condition? 
 Body part: 
 : Percentage: 
 % 
 Body part: 
 ; Percentage: 
 % 
 M 
 Physician signature: Dr Cassandra Bell, MD 
 Date: 2016/18/03
