Treating Physicians Opinion, Based Up on Objective Medical Findings, Of Patient's Residual Functional Capacity
Patient:
SSN:
Patient's Symptoms: _________________________________________________________________
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Patient's Medical History: __________________________________________________________________
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Findings of Most Recent Examination: ___________________________________________________________________
Diagnoses: __________________________________________________________________
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Treatment: ______________________________________________________________________
In my medical opinion, out of an 8 hour work day this patient is able to (circle answers):
Standing at one time:
None 15 min 30 min 60 min 2 hrs 4 hrs
Sitting at one time:
None 15 min 30 min 60 min 2 hrs 4 hrs
Lifting on an occasional basis:
None 15 min 30 min 60 min 2 hrs 4 hrs
Lifting on a frequent basis:
None 15 min 30 min 60 min 2 hrs 4 hrs
Bending:
Never Occasionally Frequently Constantly
Stooping:
Never Occasionally Frequently Constantly
Balancing:
Never Occasionally Frequently Constantly
Manipulation of Right Hand:
Never Occasionally Frequently Constantly
Manipulation of Left Hand:
Never Occasionally Frequently Constantly
Raising Left Arm over Shoulder Level:
Never Occasionally Frequently Constantly
Raising Right Arm over Shoulder Level:
Never Occasionally Frequently Constantly
Need to elevate legs during 8 hour workday:
Never Occasionally Frequently Constantly
Number of days of work per month that patient would likely miss due to impairments:
None One Two More than two
In my opinion, the patient suffers from pain that is:
None Mild Moderate Severe Extreme
Estimated date that these limitations began: ____________________________________
Comments: ______________________________________________________________________
Date :_________________________________________________________________
Medical Provider Signature
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Medical Provider Name Printed
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