RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE
Name of Claimant: _____________________________ SSN: _______________________
DEAR
DOCTOR: PLEASE COMPLETE THE FOLLOWING ITEMS BASED ON YOUR CLINICAL EVALUATION OF
THE CLAIMANT AND OTHER TESTING RESULTS. ANY ITEMS THAT YOU DO NOT BELIEVE YOU CAN ANSWER SHOULD
BE MARKED N/A (NOT ANSWERABLE). NOTE: IN
TERMS OF AN 8 HOUR WORKDAY: "OCCASIONALLY" EQUALS 0% TO 33% (1-2
HRS); "FREQUENTLY" 34% TO 66% (3-5 HRS); AND "CONTINUOUSLY"
67% TO 100% (6 TO 8
HRS).
___________________________________________________________________________________
I.
In an 8-hr. workday, claimant can: (Circle full
capacity for each activity)
A.
Sit - No. hrs. - 0, 1, 2, 3, 4, 5,
6, 7, 8.
B.
Stand - No. hrs. - 0, 1, 2, 3, 4, 5, 6, 7, 8.
C.
Walk - No. hrs. - 0, 1, 2, 3, 4, 5, 6, 7, 8.
D. Work - No. hrs. - 0, 1, 2, 3, 4, 5, 6,
7, 8.
(Sitting,
standing or walking)
____________________________________________________________________________________
II.
Claimant can lift:
Never
Occasionally Frequently Continuously
A. Up to 10 lbs. (___) (___)
(___)
(___)
B. 11 - 20 lbs. (___)
(___) (___)
(___)
C. 21 - 50 lbs. (___)
(___) (___)
(___)
D.
51 - 100 lbs (___)
(___) (___)
(___)
Limitations
due to:
____________________________________________________________________________________
III.
Claimant can carry:
Never
Occasionally Frequently
Continuously
A. Up to 10 lbs. (___)
(___)
(___) (___)
B. 11 - 20 lbs. (___)
(___)
(___) (___)
C. 21 - 50 lbs. (___)
(___)
(___) (___)
D.
51 - 100 lbs (___)
(___)
(___) (___)
Limitations
due to:
____________________________________________________________________________________
IV.
Claimant can use hands for repetitive action such as:
Simple
Grasping Pushing & Pulling Fine Manipulation
A.
Right (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No
B.
Left (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No
Limitation
due to :
____________________________________________________________________________________
V.
Is there evidence of any disorder that would limit in any way repetitive hand action
involving:
Simple
Grasping Pushing & Pulling Fine Manipulation
A.
Right (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No
B.
Left (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No
Limitation
due to :
Name:
_____________________________________ SSN
_______________________________
VI.
Claimant can use feet for repetitive movements as in operating foot controls:
Right
Left Both
(__)
Yes (___) No (__) Yes (___) No (__) Yes (___) No
Limitation
due to:
Page 2
____________________________________________________________________________________
VII.
Claimant is able to:
Never Occasionally Frequently Continuously
A.
Bend (___) (___)
(___) (___)
B.
Squat (___) (___)
(___) (___)
C.
Crawl (___) (___)
(___) (___)
D.
Climb (___)
(___) (___)
(___)
E.
Reach above (___) (___)
(___) (___)
F.
Stoop (___)
(___) (___)
(___)
G.
Crouch (___)
(___) (___)
(___)
H.
Kneel (___)
(___) (___)
(___)
Limitations due to: \
VIII.
Claimant can tolerate:
Not at all Occasionally
Frequently Continuously
A.
Exposure to unpro-
tected heights
(___) (___)
(___) (___)
B.
Being around
moving
machinery (___)
(___) (___)
(___)
C.
Exposure to marked
temperature
changes (___) (___)
(___) (___)
D.
Driving automotive
equipment
(___) (___)
(___) (___)
E.
Exposure to dust,
fumes
& gases (___)
(___)
(___) (___)
F.
Exposure to noise (___)
(___) (___)
(___)
G.
Other __________ (___) (___)
(___)
(___)
Limitations
due to:
____________________________________________________________________________________
IX.
Objective signs of pain:
(___)
Redness (___) Joint deformity (___) Spinal deformity (___) X-ray (___)
Muscle
spasm (___) Other (specify)
_______________________________________________
____________________________________________________________________________________
X.
Pain is:
(___)
Mild (would constitute an awareness but causing no handicap in the performance
of the
particular
activity, would be considered as nonratable permanent
disability).
(___)
Slight (could be tolerated but would cause some handicap in the performance of
the
activity
precipitating pain).
(___)
Moderate (could be tolerated but would cause marked handicap in the performance
of the
activity
precipitating pain).
(___)
Severe (would preclude the activity precipitating the pain).
____________________________________________________________________________________
Name: ____________________________________ SSN _______________________________
Remarks:
__________________________________________________________________________
______________________________
_____________________________________
(Date)
(Signature of Physician)
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