Residual Functional Capacity Form Page 2

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5. Please describe any treatment done so far and the results of treatment:
6. What is your prognosis for this patient?
7. Would you expect the patient’s disability or impairment to last one year or more, or has it
already lasted one year?
Yes _____ No _____
8. Does the disability or impairment prevent the patient from standing for six to eight
hours?
Yes _____ No _____
Can the patient stand at all, and if so for how long?
9. Does the disability or impairment prevent the patient from sitting upright for six to eight
hours?
Yes ______ No ______
Can the patient s t at all, and if so for how long?

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