Functional Capacity Evaluation Form Page 2

1. Have you ever had a heart attack?

YES or NO

2. Have you had heart surgery?

YES or NO

3. Have you had an abnormal electrocardiogram?

YES or NO

4. Do you have heart disease?

YES or NO

5. Have you been told by a physician you have had angina?

YES or NO

6. Have you been told by a physician you have had palpitations?

YES or NO

7. Have you had a stroke?

YES or NO

8. Are you pregnant?

YES or NO

9. Do you have high blood pressure or have you ever been treated

for high blood pressure (>150/95)?

YES or NO

10. Are you currently being treated for any other medical condition?

YES or NO

If you have any questions, please contact us at the number above. We are looking

forward to meeting you and assisting you in your rehabilitation.

Sincerely,

Wellspan Rehabilitation

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Parent category: Medical