HEALTHCARE PRACTITIONER/ FUNCTIONAL ABILITIES FORM
Worker’s Last Name:
First Name:
Claim No.
The following information should be completed by the Healthcare Professional to identify the patient’s overall
abilities and restrictions.
Date of Assessment:
Please check one:
o Patient is capable of returning to work with NO RESTRICTIONS.
DAY / MONTH / YEAR
o
_______ / _______ / _______
o
Patient is capable of returning to work WITH RESTRICTIONS. Complete
sections 1 & 2.
Patient is physically unable to return to work at this time. Complete
section 2.
SECTION 1
Please indicate abilities that apply. Include additional details in section 3.
Walking
Standing
Sitting
___ Full Abilities
____ Full Abilities
____ Full Abilities
____ Full Abilities
____ Up to 5 kilograms
____ 5-10 kilograms
____ Other (please specify
____ Up to 100 meters
____ 100-200 meters
____ Other (please specify)
____ Up to 15 min.
____ 15-30 min.
____ Other (please specify)
Stair climbing
___ Full Abilities
Ladder climbing
Travel to work
Lifting from waist to shoulder
____ Full Abilities
____ 1 - 3 steps
____ 4 – 6 steps
____ Other (please specify)
Ability to use public transit
____ YES ____ NO
Ability to drive a car
____ YES ____ NO
____ Full Abilities
____ Up to 5 kilograms
____ 5-10 kilograms
____ Other (please specify
____ Up to 5 steps
____ 5-10 steps
____ Other (please specify)
____ Up to 30 min.
____ 30 min. – 1 hr.
____ Other (please specify)
Lifting from floor to waist
SECTION 2
Please indicate restrictions that apply. Include additional details in section 3.
____ Bending/ twisting or repetitive movement of ___________________
____ Work at or above shoulder activity
_____ Chemical exposure to ______________________________________
____ Operate motorized equipment (e.g. forklift)
_____ Environmental exposure to __________________________________
_____ Exposure to vibration:
_____ Whole body
______ Hand/ arm
_____ Potential side effects from medications (please specify). Do not include names of medication.
_____ Limited pushing/ puling with: _____ Left arm _____ Right arm _____ Other (please specify)
_____ Limited use of hands:
LEFT _____ Gripping _____ Pinching _____ Other (please specify)
RIGHT _____ Gripping _____ Pinching _____ Other (please specify)
SECTION 3
Additional comments on abilities and or restrictions:
SECTION 4
From the date of assessment, the above will apply for approximately:
_____ 1 - 2 days _____ 3 - 7 days _____ 8 - 14 days _____ 14 days +
SECTION 5
Have you discussed return to work with your patient?
_____ YES _____ NO
SECTION 6
Recommendation for work hours:
Start Date: DAY / MONTH / YEAR
_____ Regular full-time hrs. _____ Modified hrs. _____ Graduated hrs.
______ / ________ / ______
Recommended date of next appointment to review abilities and/ or restrictions:
DAY / MONTH / YEAR
______ / _______ / ______
I have provided this completed Functional Abilities Form to :
_____ Worker and/ or ______ Employer
Physician’s Signature:
Print Name:
Date:
Phone: (607) 732. 7354
111 North Main Street Elmira, New York 14901
[email protected]
Fax: (888) 315.6608