Independent Medical Evaluation - Estimated Functional Capacity Form

	Estimated Functional Capacity Form

Please fill out the estimated functional capacity form and press submit at the bottom of the form to send it to us. Fields marked with a * are required.

Client Name* :
*Address:**
Address (continued):
*City, State:**	,
*Zip:**
*Claim #:**

*Evaluator Name:**
Company:
Telephone Number:
Address:
Address (continued):
City, State:	,
Zip:

*Employee Name / Claimant:**
Job Title:
Job Location:

*Employer / Company:**
Contact:
Employer Address:
Address (continued):
City, State:	,
Zip:
*Telephone:**

Claimant Information

Based on the claimant's performance during this evaluation, would you expect the claimant to be able to work eight (8) hours? Yes No

If no, how many hours?

Assuming an eight (8) hour workday with two fifteen (15) minute breaks and half hour meal break, I would expect this claimant to be able to:

NOTE: Total does not have to equal 8 hours		Continuously
Sit	hours
Stand	hours
Walk	hours
Alternate sit/stand/walk	hours
Drive	hours
Comments

	Amount (lbs)	Occasionally	Frequently	Continuously
1. Claimant can lift:
a. Floor to waist
b. Waist to shoulder
c. Shoulder to overhead

2. Claimant can carry

2b. Claimant can push/pull

Lift / Carry / Push-Pull Comments

	Never	Occasionally	Frequently	Continuously
3. Claimant able to:
a. Bend/Stoop from waist
b. Squat
c. Crawl
d. Climb Stairs
e. Climb Ladder
f. Kneel
g. Balance
Comments

4. Claimant can work with arms in the following positions:
		Above Shoulder Level	Below Shoulder Level
	Right	Yes No	Yes No
	Left	Yes No	Yes No
	Comments

5. Claimant can use hands for repetitive actions such as:
		Gross Movements	Pushing and Pulling of Arm Control	Fine Movements
	Right	Yes No	Yes No	Yes No
	Left	Yes No	Yes No	Yes No
	Comments

6. Claimant can use feet for repetitive movements as in the operating of leg controls:
	Right	Yes No
	Left	Yes No
	Both	Yes No
	Comments

Occasionally

Frequently

Continuously

7. Claimant can use head and neck in:

a. Flexion

b. Extension

c. Rotation

Physical Demand Classification of Worker
(refer to chart below):

Physical Demand Category	Occassional 1% - 33%	Frequent 34% - 66%	Constant: 67% - 100%
Sedentary	Up to 10#	None	None
Light	Up to 20#	Up to 10#	None
Medium	Up to 50#	Up to 20#	Up to 10#
Heavy	Up to 100#	Up to 50#	Up to 20#
Very Heavy	Over 100#	Over 50#	Over 20#

From the Dictionary of Occupational Titles

Comments


8. Occupational History


9. Critical Job Demands


10. Symptom Reports


11. Body Mechanics


12. Consistency of Effort


13. Recommendations


14. Comments