Residual Functional Capacity Evaluation - Delaware Disability
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3Residual Functional Capacity Evaluation
Your Patient
;
SS#
1. Frequency and length of contact: ___________________________________________________________
2. Diagnosis: ____________________________________________________________________________
3. In an 8 hour workday, how many pounds can your patient lift or carry?
0; 5; 10; 15; 20; Frequently (2/3 of 8 hour day)
0; 5; 10; 15; 20; Occasionally (1/3 of 8 hour day)
4. How long can your patient stand and/or walk?
at one time __________________
total time in an 8 hour workday _______________
5. How long can your patient sit?
at one time __________________
total time in an 8 hour workday _______________
6. If your patient has the option to alternate at will between sitting and standing, what is the maximum amount of time in an 8
hour workday that your patient can remain at a workstation?
_______________ hours per day
If the answer to question 6 is greater than or less than the sum of the answers to questions 4 and 5, please explain:
__________________________________________________________________
7. How long total during an average 8 hour workday will your patient be required to do the following:
Never
30 minutes
1 to 2
More than 2
to 1 hour
hours
hours
Lie down
___
___
___
___
Elevate legs at hip level or higher
___
___
___
___
8. Aside from scheduled breaks (i.e., 15 minutes in the morning, 30-60 minutes for lunch, and 15 minutes in the afternoon),
will your patient sometimes need to take unscheduled breaks during an 8-hour working day?
YES NO
If yes, 1) in your opinion, how many unscheduled breaks per day will your patient need? ____________
2) how many minutes (on average) will these unscheduled breaks last? ____________________
3) on an unscheduled break, will your patient have to
__ lie down
__ elevate legs at hip level or higher
__ rest head on a high back chair
__ walk around
__ other—describe:________________________________________________________
9. Does your patient experience side effects as a result of his/her prescribed medication(s)? YES NO
If YES, describe the effect on your patients ability to concentrate:
MILD* - MODERATE* - SEVERE
*
10. Does your patient suffer from pain? YES NO
If YES, how would you describe the pain generally?
MILD* - MODERATE* – SEVERE*
Linarducci & Butler, PA – RFC
(Page 1 of 3)
*
See definitions on page 3
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Parent category: Medical