Physical Capacities Evaluation Form (Page 2 of 2) in pdf

Physical Capacities Evaluation Form Page 2

CLINICAL ASSESSMENT OF PAIN

PATIENT: ___________________________________

SSN: ___________________________

Dear Doctor:

Although pain accompanying an injury or impairment is highly subjective and difficult to

measure, it is possible for the treating physician to estimate the degree of pain that is present

in a particular instance, given the nature of the impairment, the degree to which pain is

typically of major concern in that impairment, and the extent to which the patient expresses

the presence of pain and requests medication for its relief.

PLEASE ANSWER THE FOLLOWING QUESTIONS AS THEY RELATE TO THE

PATIENT LISTED ABOVE ACCORDING TO YOUR BEST CLINICAL JUDGMENT.

1. To what extent is pain of significance in the treatment of this patient. (CIRCLE ONE)

a. Pain is not present on a frequent basis to any significant degree.

b. Pain is present but does not frequently prevent functioning in everyday activities or work.

c. Pain is frequently present to such an extent as to be distracting to the adequate performance

of work activities.

d. Pain is frequently present and found to be intractable and virtually incapacitating to this

individual.

________________________________________________________________________________

2. In your best judgment, to what extent will the prescribed medication impact upon this

person’s ability to perform work-related activities? (CIRCLE ONE)

a. Medications do not have any significant effect upon this individual’s ability to work.

b. Medications can cause side effects which impose some limitations upon this patient but not

to such a degree as to create serious problems in most instances.

c. Medication side effects can be expected to be severe and to limit patient’s effectiveness due

to distracting, inattention, drowsiness, etc.

d. Patient will be totally restricted and thus unable to function at a productive level of work as

a result of medications.

________________________________________________________________________________

ATTENDING PHYSICIAN’S SIGNATURE:

______________________________________

PRINT NAME:

______________________________________

DATE:

______________________________________

Physical Capacities Evaluation Form Page 2