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Functional Capacity Evaluation Form

Asks about date of evaluation, referring provider, and job title / occupation. Built for post-injury return-to-work readiness evaluation.

Questions
16
Pages
2
Time
about 4 min
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Your practice

Functional Capacity Evaluation Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Post-injury return-to-work readiness evaluation
  • Worker's compensation functional capacity documentation
  • Disability determination and impairment rating assessments
  • Pre-employment physical demand fitness screening

What's inside

Before you publish: Clinical review required: this worksheet does not calculate scores, diagnose, or recommend treatment. Confirm the questions and response options against your approved assessment protocol before use.

Page 1 · Your information

  1. Patient NameText · Required
  2. Date of EvaluationDate
  3. Referring ProviderText
  4. Job Title / OccupationText
  5. Lifting Capacity (Floor to Waist)Number

Page 2 · Additional details

  1. Sitting Tolerance (minutes)Number
  2. Grip Strength (R/L)Text
  3. Physical Demand LevelLong Text
  4. Effort ConsistencyLong Text
  5. Pain During TestingLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Functional Capacity Evaluation Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Functional Capacity Evaluation Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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