Example of Residual Functional Capacity Questionnaire for SS

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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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