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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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