Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Functional Capacity Evaluation Form
Your information
Patient Name *
Date of Evaluation
____ / ____ / ________
Referring Provider
Job Title / Occupation
Lifting Capacity (Floor to Waist)
Carrying Tolerance
Standing Tolerance (minutes)
Walking Tolerance (minutes)
Additional details
Sitting Tolerance (minutes)
Grip Strength (R/L)
Physical Demand Level
Effort Consistency
Pain During Testing
Heart Rate Response
Functional Limitations
- Walking
- Sitting
- Standing
- Lifting
- Sleeping
- Climbing Stairs
- Driving
- Work Activities
Return-to-Work Recommendation
Functional Capacity Evaluation Form template from formisoft.com. formisoft.com/intake-templates/functional-capacity-evaluation