Exhibit — USA v. ADRIENNE PONZO (Dkt. 23.4)

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Case 1:23-mj-02053-AMD Document 23-4 Filed 04/06/26 Page 1 of 2 PageID: 83
EXHIBIT C
1:23-mj-02053-AMD Document 23-4 Filed 04/06/26 Page 2 of 2
DELAWARE WORKERS' COMPENSATION
PHYSICIAN'S REPORT OF WORKER'S COMPENSATION INJURY
A COPY OF THIS REPORT MUST BE SENT TO THE INJURED WORKER, EMPLOYER AND THE INSURER
REPORT TYPE: __ Initial X Progress __ Closing
WORKER'S NAME: Adrienne Ponzo
DOB: [illegible]1/[illegible][illegible]/1[illegible]7[illegible]
Date of Injury:
Body Part(s):
EXAM DATE: 03/26/2026
Physician's Phone/Fax: (302) 731-2[illegible][illegible][illegible]/(302) 355-4434
Employer Name:
Employer Phone/Fax: /
Insurer Name:
Insurer Claim No.:
Insurer Phone/Fax:
INITIAL VISIT ONLY
Injured worker's description of accident/injury:
WORK RELATED MEDICAL DIAGNOSIS (ES): Muscle spasm of back (M62.830)
TREATMENT PLAN:
Diagnostic Tests:
Procedures:
Therapy: Rise PT
Medications:
Hrs. per day patient can work: __ 8+ __ 8 __ 6 __ 4 __ 2 X 0
D.O.T Classification of Work
__ Sedentary: Exerting up to 10 lbs. of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
__ Light: Exerting up to 20 lbs. of force occasionally and/or up to 10 lbs. of force frequently and/or negligible amount of force constantly to move objects. Physical Demand requirements are in excess of those for Sedentary Work.
__ Medium: Exerting 20 to 50 lbs. of force occasionally and/or 10 to 25 lbs. of force frequently and/or greater than negligible up to 10 lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work.
__ Heavy: Exerting 50 to 100 lbs. of force occasionally and/or 25 to 50 lbs. of force frequently and/or 10 to 20 lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Medium Work.
__ Very Heavy: Exerting in excess of 100 lbs. of force occasionally and/or in excess of 50 lbs. of force frequently and/or in excess of 20 lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Heavy Work.
Definitions:
Occasionally: activity or condition exists up to 1/3 of the time
Frequently: activity or condition exists from 1/3 to 2/3 of the time
Constantly: activity or condition exists from 2/3 or more of the time
Work Postures/Positional tolerances: Comment as appropriate in the space provided regarding the patient's abilities/limitations for the following Postures/Positions. (e.g. Sitting: No more than 30 minutes continuously)
Sitting:
Standing:
Walking:
Driving:
Bending:
Turn/Twist:
Kneeling:
Squatting:
Crawling:
Climbing:
Repeated arm motions:
Repetitive user of wrist/hands:
Reaching up above shoulder:
Foot controls:
Comments: NO WORK 03/26/2026 to 05/14/2026 Until Next Office Visit
Above safe work capacities are: __ temporary __ permanent __ anticipate full duty release
Return to work modified duty start date:
RELEASE TO FULL DUTY WITH NO RESTRICTIONS __ YES (Start Date ___) __ NO
[signature]
Physician Signature:
Physician Name: Alexandre Mikhail PA-C Certified Provider: X YES __ NO "References the Healthcare Practice Guidelines adopted pursuant to the 19 Del.C. §2322(A)"
Date: 03/26/2026 Next Appointment: 05/14/2026


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