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Example of Residual Functional Capacity Questionnaire for SS

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 :

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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:

____________________________________________________________________________________

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).

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Name: ____________________________________ SSN _______________________________

Remarks:

____________________________________________________________________________________

______________________________                   _____________________________________

(Date)                                                                      (Signature of Physician)

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