Form No.

CLMS K534-02 (B)

PART III – ATTENDING PHYSICIAN’S CERTIFICATION (FILL IN ALL ITEMS)

Name of Employee: Treatment (Exact Date)

From:_________________ To________________
History of present illness: (give exact date; if possible Pertinent P.E. findings & Laboratory procedure
include signs & symptoms up to the time of this period.)

Past History (only those relevant to present illness)

Final Diagnosis:

Degree of disability: Was the patient working at the time of illness?

[ ] Temporary Total
[ ] Permanent Total
[ ] Permanent Partial
 Medical Evaluation Report (GSIS use only)

____________________________M.D.
Signature over printed name

PMA NO. ________________ BIR TIN NO. _________________

LIC NO. _________________ DATE ISSUED ________________

Was the injury or illness caused by the employee’s duties? _____________________