Gregory Henry

 
 2015-07-05FRI 01:07 PM NBH OCCUPATIONAL HEALTH 
 FAX NO. 5097002
 P. 32
 PRIMARY TREATIN PHYSICIAN'S PROGRESS F EPORT (PR-2) 
 Work Status: This patient has been instructed to 
 Remain off work until 
 Return to modified workton 
 2018-06-08
 with the following limitations or 
 restrictions No Lift/Push/Pull/CarryOver 15 Lbs; No Bending/Stooping; 10 Min Break Each Hr To Sit Down 
 (List all specific estrictions re standing, sitting, bending use of hands etc) 
 Return to fulliduty on 
 with no limitations OI restrictions 
 Primary Treating Physician: (original signature, do not stamp) 
 Date of exam: 
 2014-24-06 
 I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not 
 violated Labor Code 搂 139.3. 
 Signature: 
 Cal. Lic. #: C33961 
 Executed at: 
 Solano County, CA 
 Date: 
 2015-07-05
 Name: 
 Brian Gould PhD MD 
 Specialty: 
 Address: 1101 B Gale Wilson Blvd Suite 203, Fairfield, CA 94 
 Phone: 
 5097002 
 DWC Form PR-2 
 2 
 (Rev. 06-05) 
 32
