Residual Functional Capacity Ssa Listed Disorders Page 7
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1316. STOOPING bending the body downward and forward by bending the spine at the waist
(check one)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
17. POSTURES of Neck:
A) Forward Flexion (i.e. Looking down at a table or desk)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
B) Backward Flexion (i.e. Looking upward to ceiling/sky)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
C) Rotation Right (i.e. Looking sideways to right)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
D) Rotation Left (i.e. Looking sideways to left)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
REPETITIVE USE OF HANDS
Which is the individual’s physical dominant hand (circle one): Right or Left
A) Reaching (i.e. extending the hands and arms in any direction)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
RIGHT HAND
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
LEFT HAND
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
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