Functional Capacity Evaluation Form

The Functional Capacity Evaluation (FCE) Form provides a structured framework for documenting a comprehensive assessment of a patient's physical functional abilities relative to work demands and daily activities. It captures objective measurements of lifting capacity, carrying tolerance, positional tolerances (sitting, standing, walking, climbing), manual dexterity, grip strength, and endurance across sustained and repetitive activities. These measurements are compared against job-specific physical demand levels as defined by the Dictionary of Occupational Titles.

The form includes sections for documenting observed effort consistency, pain behavior during testing, and validity indicators that help clinicians assess whether the patient demonstrated maximal effort during the evaluation. It captures patient-reported limitations alongside objective findings, creating a comprehensive picture of functional abilities. Cardiovascular response monitoring fields track heart rate and blood pressure at rest and during exertion to ensure safe testing parameters.

Critical for occupational medicine clinics, physical therapy practices, rehabilitation centers, worker's compensation programs, and disability determination services, this form supports evidence-based decisions regarding return-to-work readiness, job modification recommendations, disability ratings, and long-term functional prognosis. It is appropriate for both pre-employment fitness assessments and post-injury or post-surgical functional evaluations.