Residual Functional Capacity Evaluation - Delaware Disability Page 2

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11. Does your patient’s pain or other symptoms interfere with his/her ability to complete an 8 hour workday?
 YES  NO
If YES, 1) how many days per month would you expect your patient to miss work as a result of pain or other
symptoms? _____________________________________________________________
2) how many days per month would you expect your patient to miss at least 1 hour of work (either be tardy
or have to leave work early) as a result of pain or other symptoms? ________________
12. How often can your patient perform the following activities in an 8-hour workday?
Never
Rarely
Occasionally
Frequently
1% to 5%
6% to 33%
34% to 66%
___
___
___
___
Twisting
Stooping (bend downward and forward
___
___
___
___
by bending the spine at the waist)
Crouching/ squatting
___
___
___
___
___
___
___
___
Climbing ladders
Climbing stairs
___
___
___
___
Reaching (including overhead)
___
___
___
___
___
___
___
___
Handling (gross manipulation)
Fingering (fine manipulation)
___
___
___
___
Feeling
___
___
___
___
___
___
___
___
Pushing/Pulling
If you marked “never” or rarely” for any of the areas above, please explain why: ____________________
___________________________________________________________________________________
___________________________________________________________________________________
13. Do emotional factors contribute to the severity of your patient’s symptoms and functional limitations?
 YES  NO
14. Identify any psychological conditions affecting your patient’s physical condition:
__ Depression
__ Anxiety
__ Somatoform Disorder
__ Personality disorder
__ Other: ____________________________________________________
15. Please describe any other limitations that would affect your patient's ability to work at a regular job on a sustained basis:
__________________________________________________________________________
_______________________________________________________________________________________
16. Are your patient’s physical and/or emotional impairments reasonably consistent with the symptoms and functional limitations
described in this evaluation?
 YES  NO
If NO, please explain: _________________________________________________________________
Linarducci & Butler, PA – RFC
(Page 1 of 3)

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