Kylie Wong

 
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 205 
 Work Wellness 
 July 25, 2018 
 1341 Colorado Ave Ste 134 Turlock, CA 93482 
 Page 1 
 (234) 234-3343 Fax: (349) 346-3340 
 Patient Information 
 For : Kylie Wong
 Work Status Report 
 Date of Report: 2019 December 05
 Time In: 10:11 AM 
 Time Out: 10:06 AM 
 injury date: 2022 January 16 
 Diagnosis: 
 Gallstones (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 
 signature: Jennifer S Wong DO (2019 September 05) 
 Patient Signature: 
 Ed Foster 
 Date: 2021 December 05 
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 pr tae 0345
