Functional Capacity Evaluation Paperwork - Wellspan Rehabilitation

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Wheatlyn
Deatrick Commons
Adams Health Center
SPORT Center
235 Rosedale Dr.
16C Deatrick Dr.
40 V-Twin Dr., Suite 101
207 Blooming Grove Rd.
Manchester, PA 17345
Gettysburg, PA 17325
Gettysburg, PA 17325
Hanover, PA 17331
Phone: 717.812.7400
Phone: 717.339.2540
Phone: 717.339.2620
Phone: 717.632.3431
Fax: 717.268.0193
Fax: 717.337.2977
Fax: 717.339.2621
Fax: 717.633.5143
FUNCTIONAL CAPACITY EVALUATION PAPERWORK
This is a very comprehensive series of tests, which includes testing for strength,
flexibility, lifting, pushing, pulling, carrying, bending and other work activities. This test
takes up to 6 hours so it is very important that you be here on time. Due to the length and
nature of the evaluation, we do not permit children, family members or acquaintances to
observe the evaluation. An interpreter is permitted.
We also strongly suggest you eat breakfast or lunch on the evaluation day. Please avoid
drinking any beverages containing caffeine (coffee, tea, soda) or smoking 2 hours prior to
the evaluation as this elevates blood pressure and heart rate. A resting heart rate and
blood pressure will be taken prior to the evaluation, and if the readings are too high, then
the evaluation will not be completed.
You should dress casually in loose fitting clothes and comfortable shoes, no sandals or
open-toed shoes or heels. If you are required to wear special shoes, clothes, tool belts,
etc., for your job, please bring these items with you to help us more accurately test to
your occupational demands.
Please take your medications as prescribed on the day of the evaluation.
Please be sure to bring a prescription from your physician, a copy of your medical
records and a job description if available.
You may be asked to read and complete a number of forms and questionnaires prior to or
during your evaluation. If you are unable to read or speak English please bring someone
with you who can interpret for you.
IMPORTANT: If you must cancel your appointment please do so no later than 24 hours
before your scheduled appointment. Failure to do so could result in a $200 cancellation
fee being charged.
Since the Functional Capacity Evaluation can be very strenuous it is important we know
of any heart conditions or problems prior to your participation in this evaluation. We ask
that you answer the following questions regarding heart disease and bring them to your
appointment. If you have answered yes to any of the questions, please contact the
location you have been scheduled at. Failure to do so could result in the cancellation of
your appointment. A positive response may require further physician approval before
your participation in the Functional Capacity Evaluation.
Wheatlyn
Deatrick Commons
Adams Health Center
SPORT Center
235 Rosedale Dr.
16C Deatrick Dr.
40 V-Twin Dr., Suite 101
207 Blooming Grove Rd.
Manchester, PA 17345
Gettysburg, PA 17325
Gettysburg, PA 17325
Hanover, PA 17331
Phone: 717.812.7400
Phone: 717.339.2540
Phone: 717.339.2620
Phone: 717.632.3431
Fax: 717.268.0193
Fax: 717.337.2977
Fax: 717.339.2621
Fax: 717.633.5143
FUNCTIONAL CAPACITY EVALUATION PAPERWORK
This is a very comprehensive series of tests, which includes testing for strength,
flexibility, lifting, pushing, pulling, carrying, bending and other work activities. This test
takes up to 6 hours so it is very important that you be here on time. Due to the length and
nature of the evaluation, we do not permit children, family members or acquaintances to
observe the evaluation. An interpreter is permitted.
We also strongly suggest you eat breakfast or lunch on the evaluation day. Please avoid
drinking any beverages containing caffeine (coffee, tea, soda) or smoking 2 hours prior to
the evaluation as this elevates blood pressure and heart rate. A resting heart rate and
blood pressure will be taken prior to the evaluation, and if the readings are too high, then
the evaluation will not be completed.
You should dress casually in loose fitting clothes and comfortable shoes, no sandals or
open-toed shoes or heels. If you are required to wear special shoes, clothes, tool belts,
etc., for your job, please bring these items with you to help us more accurately test to
your occupational demands.
Please take your medications as prescribed on the day of the evaluation.
Please be sure to bring a prescription from your physician, a copy of your medical
records and a job description if available.
You may be asked to read and complete a number of forms and questionnaires prior to or
during your evaluation. If you are unable to read or speak English please bring someone
with you who can interpret for you.
IMPORTANT: If you must cancel your appointment please do so no later than 24 hours
before your scheduled appointment. Failure to do so could result in a $200 cancellation
fee being charged.
Since the Functional Capacity Evaluation can be very strenuous it is important we know
of any heart conditions or problems prior to your participation in this evaluation. We ask
that you answer the following questions regarding heart disease and bring them to your
appointment. If you have answered yes to any of the questions, please contact the
location you have been scheduled at. Failure to do so could result in the cancellation of
your appointment. A positive response may require further physician approval before
your participation in the Functional Capacity Evaluation.
1. Have you ever had a heart attack?
YES or NO
2. Have you had heart surgery?
YES or NO
3. Have you had an abnormal electrocardiogram?
YES or NO
4. Do you have heart disease?
YES or NO
5. Have you been told by a physician you have had angina?
YES or NO
6. Have you been told by a physician you have had palpitations?
YES or NO
7. Have you had a stroke?
YES or NO
8. Are you pregnant?
YES or NO
9. Do you have high blood pressure or have you ever been treated
for high blood pressure (>150/95)?
YES or NO
10. Are you currently being treated for any other medical condition?
YES or NO
If you have any questions, please contact us at the number above. We are looking
forward to meeting you and assisting you in your rehabilitation.
Sincerely,
Wellspan Rehabilitation
INFORMATION/MEDICAL HISTORY
Name:______________________________________
DOB:___________________
Phone: (Home)_________________ (Work)________________ (Cell)_______________
Preferred DAYTIME contact # _______________ Next appt with referring doctor______
Current Conditions/Chief Complaint(s):
Why have you been referred for this evaluation? ________________________________
________________________________________________________________________
When did the problem begin (date)? __________________________________________
What happened? __________________________________________________________
Have you ever had the problem before? No_____ Yes _____
Please list any treatment you have participated in to manage your injury/symptoms (i.e.
therapy, injections, medications, chiropractic care, etc).
________________________________________________________________________
________________________________________________________________________
How are you managing your symptoms now? __________________________________
________________________________________________________________________
What makes the symptoms worse? ___________________________________________
Are you seeing anyone else for the problem(s)? No_____ Yes_____ (If yes, check all
that apply.)
____Acupuncturist
____Neurosurgeon
____Physiatrist (Pain Mgmt)
____Cardiologist
____Orthopedist
____Chiropractor
____Primary Care Physician
____Podiatrist
____Internist
____Massage Therapist
____Rheumatologist
____Neurologist
____Other: _______________________
Please list all physicians that are currently involved in your health care:______________
_______________________________________________________________________
Clinical Tests:
Within the past year, have you had any of the following tests? (Check all that apply.)
____Angiogram
____MRI
____Arthroscopy
____Myelogram
____Blood Tests
____Nerve Conduction Study
____Bone Scan
____Pulmonary Function Test
____CT Scan
____Spinal Tap
____Doppler Ultrasound
____Echocardiogram
____Stress Test
____EEG
____EKG
____X-rays
____EMG
____Other: __________________________
____None of the above
Medications:
Do you take any prescription medications? No____ Yes ____ (If yes, please list any
medications you are taking or provide a list we can copy.)_________________________
________________________________________________________________________
Do you take any nonprescription medications? (Check all that apply.)
____Advil
____Aleve
____Naproxen
____Tylenol
____Aspirin
____Ibuprofen
____Decongestants
____Antacids
____Antihistimines
____Herbal Supplements
____Other:______________________________________
Have you ever had any adverse/allergic drug reactions? No____ Yes____ If yes, please
describe reaction and which medication caused it. _______________________________
Social History:
Marital Status:
____Single
____Married
____Divorced
Living Situation:
____Alone
____With Spouse
____With Children
____Other:________________________
Are there any cultural or religious concerns that might affect your care? No____ Yes____
Are you aware of any learning problems that may affect your care?
No____Yes____
Education:
____Highest grade completed (Circle one): 1 2 3 4 5 6 7 8 9 10 11 12
____Some college
____Technical school
____College graduate: Major_____________________
____Graduate school/advanced degree: Major_______________________
Functional Status/Activity Level: (Check all that apply) Do you have difficulty with
any of the following:
____Rolling or getting in and out of bed
____Getting in and out of chairs/cars
____Walking on even surfaces
____Walking on uneven terrain
____Stair Climbing
____Bathing, dressing, grooming, toileting
____Household chores, shopping, driving/transportation, care of dependents
____Work
____Recreational/Leisure activity
____No difficulties noted
What positions do you have difficulty tolerating in order to complete daily activities?
________________________________________________________________________
Please write what percentage (between 0% and 100%) of your normal activities you are
now able to perform in the following areas (0%=not able to perform, 100%=able to
perform all activities):
Leisure/Recreational Activities? ____%
Home Activities?____%
Work
Activities?____% (If not currently working, rate based on job you were performing when
you stopped working. Please do not leave blank.)
Social/Health Habits:
Smoking:
Alcohol:
____Have never smoked
____Never drink
____Have quit smoking
____Seldom drink
____Smoke pipe/cigar only
____1 to 2 time(s) per week
____Smoke____packs a day
____Daily (Quantity:___________)
Exercise:
Do you exercise beyond normal daily activities and chores? No____ Yes____
If yes, describe the exercise:___________________________________________
If yes, on average how many days per week do you exercise or do physical
activity? _______ On an average day, for how many minutes? _________
Medical/Surgical History:
Please check if you have ever had:
____Arthritis
____Seizures/epilepsy
____Broken bones/fractures
____Osteoporosis
____Thyroid problems
____Heart problems
____Infectious disease
____High blood pressure
____Cancer
____Lung problems
____Kidney problems
____Stroke
____Repeated infections
____Diabetes
____Head Injury
____Stomach problems
____Hypoglycemia/low blood sugar
____Other:______________________________________________________________
Please list any allergies you may have. ________________________________________
Within the past year, have you had any of the following symptoms? (Check all that
apply.)
____Chest pain
____Difficulty sleeping
____Heart palpitations
____Loss of appetite
____Difficulty swallowing
____Shortness of breath
____Bowel problems
____Dizziness or blackouts ____Weight loss/gain
____Loss of balance
____Headaches
____Pain at night
____Joint pain or swelling
____Difficulty walking
____Vision problems
____Hearing problems
____Other:____________________
Have you ever had surgery? No____ Yes____
If yes, please describe and include dates: ______________________________________
_______________________________________________________________________
Vocational Information:
Are you currently receiving Workers’ Compensation? No____ Yes____ If yes, please list
Insurance Company’s Name:__________________________________________
Claims Adjuster’s Name:_____________________________________________
Rehab Nurse’s Name:________________________________________________
Are you currently receiving any other disability benefits? No____ Yes____
Are you currently working? No____ Yes____ Retired____ Disabled____
If yes, are you currently working light duty? No____ Yes____
If you are currently off from work, please list the last date that you worked:___________
Employer’s Name:________________________________________________________
Contact person at company:_________________________________________________
Job Title:________________________________________________________________

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