Form Amr Di 0917 - Disability Claim Employee Statement Page 10
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12Physical Capabilities
(Check all that apply which are supported by clinical findings)
(A) The patient can perform the following in an 8-hour workday (specify percentage):
Sitting
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Standing
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Walking
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Climbing
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Bending / Stooping / Twisting
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Reaching above Shoulder Level
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Handling - Right Hand
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Left Hand
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Fingering - Right Hand
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Left Hand
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
(B) Patient’s ability to lift / carry: (check)
Up to 10 lbs.
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
11 to 20 lbs.
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
21 to 50 lbs.
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
51 to 100 lbs.
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
Over 100 lbs.
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
(C) Push / pull force:__________lbs.
M 0%
M 1-5%
M 6-33%
M 34-66%
M 67-100%
(D) Patient’s dominant hand: M Right
M Left
(E) Other work or activity restrictions. Please be specific.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Cardiac
Functional Capacity (American Heart Association) Complete only if applicable.
M Class 1 (No Limitation)
M Class 2 (Slight Limitation)
M Class 3 (Marked Limitation)
M Class 4 (Complete Limitation)
Blood pressure (latest reading)______________________ as of (date) ___________________
mm/dd/yy
Is patient in a cardiac rehabilitation program? M Yes M No
Stress test performed? M Yes M No Please attach report.
Prognosis for Return to Work
Have you advised patient to return to work?
M Yes If Yes, date of return____________________
M To regular occupation
M Full Time
M Part Time
mm/dd/yy
M No
If not, please explain.
M To any other occupation
M Full Time
M Part Time
Is patient able to return to modified work? M Yes M No
If so, specify any applicable work / activity restrictions.
Rehab
Do you suggest that the patient become involved in any of the following? Please check as many as apply.
If so, was this discussed with the patient?
M Yes M No
Dates_________________________________________________
mm/dd/yy
M Physical Therapy
M Pain Management Program
M Vocational Rehabilitation
M Occupational Therapy
M Work Hardening Program
M Psychological Counseling
M Cardiac Rehabilitation
M Job Modification
M Other___________________________
American Airlines Employer Health & Wellness Services with ActiveHealth ___________________________________
*Online and telephone health coaching for weight, diabetes, blood pressure, chronic pain, back care, quitting smoking, dealing with stress
*Call Healthmatters at 1-888-227-6598 to schedule a call with a Health Advocate team member.
Page 10 of 12
AMR DI 0917 (02/14) Fs
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