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Functional Capacity Evaluation
NAME
SSN or WID
DATE OF INJURY
DATE OF BIRTH
Client works on average of
8
10 or
12 hours per day (check one)
1. In a work day, client can (check number of hours full capacity for each activity).
a. Sit
1
2
3
4
5
6
7
8
9
10
11
12
b. Stand
1
2
3
4
5
6
7
8
9
10
11
12
c. Walk
1
2
3
4
5
6
7
8
9
10
11
12
Comments: (If appropriate, note frequency per hour or day)
NOTE: For a full regular work day “Occasionally” equals 1% to 33%, “Frequently” equals 34% to 66%, “Continuously” equals 67% to 100%
2. Client is able to: (check one)
Not at All
Occasionally
Frequently
Continuously
a. Twist
b. Bend/Stoop (lumbar)
c. Cervical Bend
d. Squat
e. Crawl
f. Climb Ladders
g. Climb Stairs
h. Reach Above Shoulder Level
i.
Crouch
j.
Kneel
k. Balance
l.
Walk on Uneven Ground
m. Work Above Ground
n. Push/Pull
o. Other:
3. Client can carry (lbs.)
Seldom
Occasionally
Frequently
Continuously
4. Client can lift (lbs.):
Seldom
Occasionally
Frequently
Continuously
a. Floor to Waist
b. Waist to Shoulder Level
c. Shoulder to Overhead
d. Waist to Waist
5. Client can used hands for frequent action such as:
Simple Grasping
Firm Grasping
Fine Manipulating
Yes
No
Yes
No
Yes
No
a. Right
Yes
No
Yes
No
Yes
No
b. Left
6. Client can use head and neck:
Not at All
Occasionally
Frequently
Continuously
a. Static position
b. Flexing
c. Rotating
7. Restriction of Activities Required by Physical Impairment
extreme cold
extreme heat
wet or humid
slippery floors
vibration
near moving equipment
drive auto/equipment
other:
8. Comments/Recommendations
SIGNATURE OF THERAPIST
DATE
SIGNATURE OF PHYSICIAN
DATE
FCE (10/29/09)
Reset
Functional Capacity Evaluation
NAME
SSN or WID
DATE OF INJURY
DATE OF BIRTH
Client works on average of
8
10 or
12 hours per day (check one)
1. In a work day, client can (check number of hours full capacity for each activity).
a. Sit
1
2
3
4
5
6
7
8
9
10
11
12
b. Stand
1
2
3
4
5
6
7
8
9
10
11
12
c. Walk
1
2
3
4
5
6
7
8
9
10
11
12
Comments: (If appropriate, note frequency per hour or day)
NOTE: For a full regular work day “Occasionally” equals 1% to 33%, “Frequently” equals 34% to 66%, “Continuously” equals 67% to 100%
2. Client is able to: (check one)
Not at All
Occasionally
Frequently
Continuously
a. Twist
b. Bend/Stoop (lumbar)
c. Cervical Bend
d. Squat
e. Crawl
f. Climb Ladders
g. Climb Stairs
h. Reach Above Shoulder Level
i.
Crouch
j.
Kneel
k. Balance
l.
Walk on Uneven Ground
m. Work Above Ground
n. Push/Pull
o. Other:
3. Client can carry (lbs.)
Seldom
Occasionally
Frequently
Continuously
4. Client can lift (lbs.):
Seldom
Occasionally
Frequently
Continuously
a. Floor to Waist
b. Waist to Shoulder Level
c. Shoulder to Overhead
d. Waist to Waist
5. Client can used hands for frequent action such as:
Simple Grasping
Firm Grasping
Fine Manipulating
Yes
No
Yes
No
Yes
No
a. Right
Yes
No
Yes
No
Yes
No
b. Left
6. Client can use head and neck:
Not at All
Occasionally
Frequently
Continuously
a. Static position
b. Flexing
c. Rotating
7. Restriction of Activities Required by Physical Impairment
extreme cold
extreme heat
wet or humid
slippery floors
vibration
near moving equipment
drive auto/equipment
other:
8. Comments/Recommendations
SIGNATURE OF THERAPIST
DATE
SIGNATURE OF PHYSICIAN
DATE
FCE (10/29/09)