Functional Capacity Evaluation Form printable pdf download

Wheatlyn

Deatrick Commons

Adams Health Center

SPORT Center

235 Rosedale Dr.

16C Deatrick Dr.

40 V-Twin Dr., Suite 101

207 Blooming Grove Rd.

Manchester, PA 17345

Gettysburg, PA 17325

Hanover, PA 17331

Phone: 717.812.7400

Phone: 717.339.2540

Phone: 717.339.2620

Phone: 717.632.3431

Fax: 717.268.0193

Fax: 717.337.2977

Fax: 717.339.2621

Fax: 717.633.5143

FUNCTIONAL CAPACITY EVALUATION PAPERWORK

This is a very comprehensive series of tests, which includes testing for strength,

flexibility, lifting, pushing, pulling, carrying, bending and other work activities. This test

takes up to 6 hours so it is very important that you be here on time. Due to the length and

nature of the evaluation, we do not permit children, family members or acquaintances to

observe the evaluation. An interpreter is permitted.

We also strongly suggest you eat breakfast or lunch on the evaluation day. Please avoid

drinking any beverages containing caffeine (coffee, tea, soda) or smoking 2 hours prior to

the evaluation as this elevates blood pressure and heart rate. A resting heart rate and

blood pressure will be taken prior to the evaluation, and if the readings are too high, then

the evaluation will not be completed.

You should dress casually in loose fitting clothes and comfortable shoes, no sandals or

open-toed shoes or heels. If you are required to wear special shoes, clothes, tool belts,

etc., for your job, please bring these items with you to help us more accurately test to

your occupational demands.

Please take your medications as prescribed on the day of the evaluation.

Please be sure to bring a prescription from your physician, a copy of your medical

records and a job description if available.

You may be asked to read and complete a number of forms and questionnaires prior to or

during your evaluation. If you are unable to read or speak English please bring someone

with you who can interpret for you.

IMPORTANT: If you must cancel your appointment please do so no later than 24 hours

before your scheduled appointment. Failure to do so could result in a $200 cancellation

fee being charged.

Since the Functional Capacity Evaluation can be very strenuous it is important we know

of any heart conditions or problems prior to your participation in this evaluation. We ask

that you answer the following questions regarding heart disease and bring them to your

appointment. If you have answered yes to any of the questions, please contact the

location you have been scheduled at. Failure to do so could result in the cancellation of

your appointment. A positive response may require further physician approval before

your participation in the Functional Capacity Evaluation.

Functional Capacity Evaluation Form

Related Articles

Related forms

Related Categories