ESTIMATED FUNCTIONAL CAPACITY EVALUATION

To be completed by treating physician.

Patient:

Definitions for your reference:

SEDENTARY WORK: lift 10# maximum and occasionally carry small objects

LIGHT WORK: lift 20# maximum; frequently lift/carry up to 10#

MEDIUM WORK: lift 50# maximum; frequently lift/carry up to 25#

HEAVY WORK: lift 100# maximum; frequently lift/carry up to 50#

VERY HEAVY WORK: lift in excess of 100#; frequently lift/carry 50#

I WOULD ESTIMATE THIS PERSON TO BE ABLE TO:
				Never				Occasionally (1-33%)					Frequently (34-66%)	Continuously (67-100%)
1. LIFT:
a. up to 10#
b. 11 - 24#
c. 25 - 34#
d. 35 - 50#
e. 51 - 74#
f. 75 - 100#
2. CARRY:
a. up to 10#
b. 11 - 24#
c. 25 - 34#
d. 35 - 50#
e. 51 - 74#
f. 75 - 100#
3. PERFORM THE FOLLOWING TASKS:
Push/Pull – Seated
Push/Pull – Standing
Bend
Squat
Crawl
Climb
Reach above shoulder level
	4. ASSUMING AN 8-HOUR WORKDAY WITH TWO 15-MINUTE BREAKS AND A HALF HOUR MEAL BREAK, I WOULD EXPECT THIS PERSON TO BE ABLE TO: Circle number of hours for each activity. NOTE: Total does not have to equal 8 hours.
	Activity	Number of Hours										Continuously			With Rests
	Sit	1	2		3	4	5		6	7	8	¨			¨
	Stand	1	2		3	4	5		6	7	8	¨			¨
	Walk	1	2		3	4	5		6	7	8	¨			¨
	Alternately Sit/Stand	1	2		3	4	5		6	7	8	¨			¨

5. CAN PERSON USE HANDS FOR REPETITIVE ACTIONS SUCH AS: