Residual Functional Capacity Form Page 4

16. Does the patient’s disability or impairment prevent the him or her from performing

certain motions such as lifting, pulling, holding objects, etc.?

17. Does the patient have any difficulty performing the motions below? (Please include any

range of motion information.)

Bending ______________________________________

Squatting ______________________________________

Kneeling ______________________________________

Turning any parts of the body _______________________

18. Would the patient’s disability or impairment prevent him or her from traveling alone?

Yes _____ No ______Why?

19. Are there any other factors not addressed in the above questions that you believe may

affect the patient’s ability to work, or function normally in daily life?

20. If the patient has any complaints of pain, please address the following questions:

What is the nature of the pain?

How frequent is the pain?

How would you describe the level of pain?

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Parent category: Medical