Physical Capacities Evaluation Form
ADVERTISEMENT
1
2PHYSICAL CAPACITIES EVALUATION
PATIENT: ___________________________________________
SSN: ___________________________________________
IMPORTANT: PLEASE COMPLETE THE FOLLOWING ITEMS BASED ON YOUR CLINICAL EVALUATION OF
THE PATIENT AND OTHER TESTING RESULTS.
ANY ITEM THAT YOU DO NOT BELIEVE YOU COULD
ANSWER SHOULD BE MARKED N/A (NOT ANSWERABLE).
NOTE: IN TERMS OF AN 8-HOUR WORKDAY, “OCCASIONALLY” EQUALS 1% TO 33%; “FREQUENTLY” 34%
TO 66%; “CONTINUOUSLY” 67% TO 100%.
1.
IN AN 8-HOUR WORKDAY, CLAIMANT CAN:
(CIRCLE FULL CAPACITY FOR EACH ACTIVITY)
TOTAL AT ONE TIME:
A) Sit
<1
1
2
3
4
5
6
7
8
(hours)
B) Stand/Walk (Combined)
<1
1
2
3
4
5
6
7
8
(hours)
TOTAL DURING ENTIRE 8-HOUR DAY:
A) Sit
<1
1
2
3
4
5
6
7
8
(hours)
B) Stand/Walk (Combined)
<1
1
2
3
4
5
6
7
8
(hours)
2.
CLAIMANT CAN LIFT:
NEVER
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
A) Up to 5 lbs
[ ]
[ ]
[ ]
[ ]
B) 6-10 lbs
[ ]
[ ]
[ ]
[ ]
C) 11-20 lbs
[ ]
[ ]
[ ]
[ ]
D) 21-25 lbs
[ ]
[ ]
[ ]
[ ]
E)
26-50 lbs
[ ]
[ ]
[ ]
[ ]
F)
51-100 lbs
[ ]
[ ]
[ ]
[ ]
3.
CLAIMANT CAN CARRY:
NEVER
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
G) Up to 5 lbs
[ ]
[ ]
[ ]
[ ]
H) 6-10 lbs
[ ]
[ ]
[ ]
[ ]
I)
11-20 lbs
[ ]
[ ]
[ ]
[ ]
J)
21-25 lbs
[ ]
[ ]
[ ]
[ ]
K) 26-50 lbs
[ ]
[ ]
[ ]
[ ]
L)
51-100 lbs
[ ]
[ ]
[ ]
[ ]
4.
CLAIMANT CAN USE HANDS FOR REPETITIVE ACTION SUCH AS:
SIMPLE GRASPING
PUSHING & PULLING (ARM CONTROLS)
FINE MANIPULATION
A) Right
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
B) Left
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
5.
CAN USE FEET FOR REPETITIVE MOVEMENTS AS IN PUSHING AND PULLING OF LEG CONTROLS
RIGHT
LEFT
BOTH
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
6.
CLAIMANT IS ABLE TO:
NOT AT ALL
OCCASIONALLY
FREQUENTLY
CONTINUOUSLY
A) Bend
[ ]
[ ]
[ ]
[ ]
B) Squat
[ ]
[ ]
[ ]
[ ]
C) Crawl
[ ]
[ ]
[ ]
[ ]
D) Climb
[ ]
[ ]
[ ]
[ ]
E)
Reach
[ ]
[ ]
[ ]
[ ]
7.
RESTRICTIONS OF ACTIVITIES INVOLVING:
NONE
MILD
MODERATE
TOTAL
A) Unprotected Heights
[ ]
[ ]
[ ]
[ ]
B) Being around moving machinery
[ ]
[ ]
[ ]
[ ]
C) Exposure to marked changes
In temperature and humidity
[ ]
[ ]
[ ]
[ ]
D) Driving automobile equipment
[ ]
[ ]
[ ]
[ ]
E)
Exposure to dust, fumes and gases
[ ]
[ ]
[ ]
[ ]
Diagnosis: _________________________________________________________________________________________________
Signature: ________________________________________________________
Date: ______________________________
Print Name: _______________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical