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NAME: SSN: PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT FORM Definitions: NEVER: 10% or less of an 8 hr. day FREQUENT: 34 - 66% of an 8 hr. day OCCASIONAL: 11 - 33% of an 8 hr. day CONSTANT: 67% or more of an 8 hr. day IMPORTANT NOTE TO PHYSICIAN COMPLETING FORM: It has been the experience of the clamant's attorney who is requesting this information that there might be some feeling that the capacity to sit, stand and walk must add up to a total of exactly eight hours; i.e., a work day. This is not the case. The total can add up to any figure; less than 8 hours (reflecting the patient's overall need to rest or limit activity because of symptoms of pain, shortness of breath, fatigue, etc.) or more than 8 hours. Please consider this when completing this form. (1) In an eight hour work day, the patient can sit, stand and walk as follows: 6 hrs TOTALS OVER COURSE OF DAY CONTINUOUSLY WITHOUT CHANGING POSITION mins 1 hr 2 hrs 3 hrs 4 hrs 5 hrs 6 hrs 7 hrs 8 hrs 7 hrs 8 hrs SIT STAND WALK 1 hr 2 hrs 3 hrs 4 hrs 5 hrs mins CONSISTENCY OVER TIME DAILY CAPACITY ADD THE "TOTALS" FOR SIT, STAND THE PATIENT'S ATTENDANCE AT WORK OVER THE & WALK COURSE OF A 5-DAY WEEK IS EXPECTED TO BE: Reliable and consistent over the course of a 5-day week hrs/day Inconsistent or sporadic due to reasonably The patient can work a Grand Total of OR I do not expect these daily capacities to be expected exacerbation of condition(s) used Cannot be expected to work more than should be used only for necessary straight days at a time for work. They Activities of Daily Living. (2) In an eight hour work day, the patient can lift as follows: Never Occasional 0 - 5 pounds 6 - 10 pounds 11 - 20 pounds 21 - 50 pounds (3) In an eight hour work day, the patient can USE HANDS FOR: Never Occasional RIGHT HAND Simple Grasping: Pulling/Pushing: Fine Manipulation: LEFT HAND Simple Grasping: Pulling/Pushing: Fine Manipulation: (4) Never describes the condition as follows: Frequent Occasional Frequent Constant Frequent Constant Constant In your opinion, does _____________________ have a medically determinable condition which could reasonably be expected to produce the type and degree of symptoms and limitations described, above? Yes - the diagnosed condition(s) causing this: No (if no - state the objective medical evidence which causes you to disbelieve this description) (5) With regard to your above medical assessment, were your findings verified by objective clinical signs and laboratory tests? Yes No (6) If your answer to Question 5 is yes, are those clinical signs and laboratory tests included in your medical records? Yes No (7) With regard to the nature and extent of pain symptoms, would you classify his pain as1Slight/None: Performance of the task is only minimally impaired due to pain symptoms; e.g., 90 percent or more of normal, and the activity can be engaged in constantly or continuously during and eight hour workday. : None or slight Moderate Moderately severe (8) Do emotional factors contribute to the severity of Yes No Severe 's symptoms and functional limitations? (9) How often are 's symptoms severe enough to interfere with attention and concentration and the ability to remember and carry out simple instructions? Never Seldom Often Frequently Constantly (10) With such treatments as medications, therapeutic exercises, and rest, is condition: Worsening Stabilizing Improving 's (11) _________________ alleges onset of disability as of ____________________ . In your opinion, would the above-stated limitations be considered to exist since that date? Yes No (If "no", state the earliest date, thereafter, you consider these limitations to have existed: ) , M.D. DATE 1 Severe: Indicates that activity is totally precluded on a sustained basis due to pain symptoms and would result in failing after even short duration; e.g., 5-15 minutes. Moderately Severe: Indicates that the activity is not totally precluded due to pain symptoms, but is substantially impaired in terms of speed or accuracy of carrying out the task and can only be engaged in occasionally or seldom during an eight hour workday; e.g., short durations (5-15 minutes) not totaling more than two hours in an eight hour workday. Moderate: Indicates that the activity is somewhat impaired due to pain symptoms (can be performed at 80-85 percent of expected or normal levels in terms of speed or accuracy of carrying out the task), but can be engaged in occasionally to frequently (1/3-2/3 of a day), but not constantly or continuously.
