Residual Functional Capacity Form Page 3

10. If the patient cannot stand and/or sit upright for six to eight hours, what is the reason?

11. Does the disability or impairment require the patient to lie down during the day?

Yes ______ No ______

If the answer is yes please explain why:

12. How far can the patient walk without stopping?

13. Please check the frequency with which the patient can perform the following activities:

Percentage of Time

Rarely 0-30%

Frequently 30-70%

Consistently 70-100%

Reach Up Above

Shoulders

Reach Down to Waist

Level

Reach Down Towards

Floor

Carefully Handle

Objects

Handle with Fingers

14. In pounds, how much weight can the patient lift and carry during an eight-hour period?

_____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50

15. In pounds, how much weight can the patient lift and carry regularly/daily?

____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50

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Parent category: Medical