Return To Work Restrictions Form Page 2
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2Specific functional restrictions and/or limitations
Patient’s name _________________________________
Check
only those items that apply in Section A, and provide details in Sections B.
Definition
Restriction: This patient is advised not to perform this activity in any capacity.
Limitation: This patient is able to perform the activity in a reduced capacity. For example, this patient is not able to
perform the job with the usual speed, strength or number of repetitions, or for the usual duration.
Section A
Restriction
Limitation
Restriction
Limitation
Physical____________________________________
Mental_______________________________________
Sitting
Thinking/Reasoning
Standing/Walking
Thinking/Reasoning
_____hrs at a time
Concentration
Lifting/Carrying
Memory
___ lb. allowable weight
Critical decision-making
Pushing/Pulling
Interpersonal contact
___ lb. allowable weight
Alertness
Climbing stairs/ladders
Other (specify in section B)
Crouching
Environmental________________________________
Crawling
Exposure to heat/cold
Kneeling
Exposure to dust/fumes
Bending
Exposure to chemicals
Twisting/Turning
Other (specify in section B)
Repetitive activity
Other________________________________________
Sustained postures
Shift/attendance duration
Gripping
Shift work
Reaching
Overtime
Fine dexterity
Operating vehicles/equipment
Balance
Working at heights
Work with vibrating hand tools
Other (specify in section B)
Section B
___________________________________________________________________
___________________________________________________________________
Return to Work Restrictions form – F602501b – r6 – fb- 05/31/13
Page 2 of 2
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Parent category: Letters