Fitness for Work Certificate

Purpose: This certificate is issued as an official confirmation of an individual’s physical and/or mental ability to perform occupational duties, following a medical assessment conducted by a licensed healthcare provider.

Patient Information

Medical Assessment

Assessment Date: {assessmentDate}

Conducted By: Dr. {physicianName}, {physicianTitle}

Findings:

• General Health Condition: {generalCondition}
• Relevant Medical History: {medicalHistory}
• Medications (if any): {medications}

Work Capability

{#isFitForWork}This individual is deemed medically fit to perform work-related tasks without restrictions.{/isFitForWork}

{^isFitForWork}This individual is currently not fit to perform work-related tasks.{/isFitForWork}

{#restrictions}

Conditional Fitness Note

The individual is fit to work under the following restrictions or limitations:

• {description}

{/restrictions}

Recommended Review Date

{reviewDate}

Physician’s Declaration

I hereby certify that I have personally examined the individual named above and that the above information is true and accurate to the best of my knowledge.

Physician Name: {physicianName}

License Number: {licenseNumber}

Signature: _______________________

Date: {issuedDate}

This document is confidential and intended solely for the review of the individual, employer, and necessary third parties.