Functional Capacity Evaluation Form Page 3

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INFORMATION/MEDICAL HISTORY
Name:______________________________________
DOB:___________________
Phone: (Home)_________________ (Work)________________ (Cell)_______________
Preferred DAYTIME contact # _______________ Next appt with referring doctor______
Current Conditions/Chief Complaint(s):
Why have you been referred for this evaluation? ________________________________
________________________________________________________________________
When did the problem begin (date)? __________________________________________
What happened? __________________________________________________________
Have you ever had the problem before? No_____ Yes _____
Please list any treatment you have participated in to manage your injury/symptoms (i.e.
therapy, injections, medications, chiropractic care, etc).
________________________________________________________________________
________________________________________________________________________
How are you managing your symptoms now? __________________________________
________________________________________________________________________
What makes the symptoms worse? ___________________________________________
Are you seeing anyone else for the problem(s)? No_____ Yes_____ (If yes, check all
that apply.)
____Acupuncturist
____Neurosurgeon
____Physiatrist (Pain Mgmt)
____Cardiologist
____Orthopedist
____Chiropractor
____Primary Care Physician
____Podiatrist
____Internist
____Massage Therapist
____Rheumatologist
____Neurologist
____Other: _______________________
Please list all physicians that are currently involved in your health care:______________
_______________________________________________________________________
Clinical Tests:
Within the past year, have you had any of the following tests? (Check all that apply.)
____Angiogram
____MRI
____Arthroscopy
____Myelogram
____Blood Tests
____Nerve Conduction Study
____Bone Scan
____Pulmonary Function Test
____CT Scan
____Spinal Tap
____Doppler Ultrasound
____Echocardiogram
____Stress Test
____EEG
____EKG
____X-rays
____EMG
____Other: __________________________
____None of the above

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