PHYSICAL CAPACITIES EVALUATION(PCE) / RESIDUAL FUNCTIONAL CAPACITY (RFC) FORM
PHYSICAL CAPACITIES EVALUATION(PCE) / RESIDUAL FUNCTIONAL CAPACITY (RFC) FORM
Patient:____________________________________ SS #:_______________
Date Of Birth:_______________
Dear Doctor:
Please answer the following questions with regard to your patient's claim for Social Security disability benefits or Supplemental Security Income (SSI) and/or with regard to your patient’s claim for Long Term Disability (LTD). Please base your answers on how your patient's medical conditions affect his or her ability to function.
1.Nature, frequency and length of contact:
2.Please describe patient's symptoms (including patient's reports of pain, dizziness, etc.):
3.State all clinical findings and laboratory/test results (or enclose copy of same): Please link findings to specific limitations.
4.Diagnosis:
5.Treatment and response (including list of medications and their effect and side-effects):
6.Prognosis:
7.Has the patient's impairment lasted, or can it be expected to last, at least twelve months?Yes _____ No _____
8.Can the patient continuously stand for at least 6 of 8 hours?Yes _____ No _____ How long CAN the patient stand? ____________
9.Can the patient continuously sit upright for at least 6 of 8 hours?Yes ______ No ______ How long CAN the patient sit upright? ______
10.If the answer to either number 8 or number 9 is NO, why is the patient unable to sit or stand?11.Does the patient have to lie down during the day? Yes ______ No ______ If yes, please explain why:12.How many city blocks can the patient walk without stopping?
Please check the frequency that the patient can perform the following activities:
Never Occ. Freq. Const.
0-33% 34-67% 68-100%
Reach Above shoulder ______ ______ ______ _______
At waist level ______ ______ ______ _______
Below waist level ______ ______ ______ _______
Handling (gross motor) ______ ______ ______ _______
Fingering (fine motor) ______ ______ ______ _______
Feeling ______ ______ ______ _______
14. How many pounds can the patient frequently lift over an 8 hour period?_____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50
15. How many pounds can the patient frequently carry?____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50
16. Does the patient have any problems performing such functions as grasping, pulling, pushing, or doing fine manipulations with his or her hands? PLEASE BE SPECIFIC.17.Does the patient have any problems with the following movements? (Please indicate any applicable range of motion studies):Bending ______________________________________Squatting ______________________________________Kneeling ______________________________________Turning any parts of the body ________________________
18. Is the patient able to travel alone? Yes _____ No ______Why?
19. Are there any other factors affecting the patient's ability to work (e.g. exposure to fumes, gases; ability to tolerate heights; restriction of exposure to moving machinery)?20. If your patient complains of any pain, please indicate the nature and severity of the complaints and your opinion of the patient's credibility with respect to his or her complaints:If there is an objective basis for the patient's pain, give specific details for this basis (i.e. degenerative changes in the spine):21. Considering your diagnosis of the patient's condition and his/her prognosis, is the patient capable of returning to his/her past job?
Yes _____ No _____ State why or why not:
22. Considering the same factors, is there any work the patient is capable of? State why or why not:___________________________________________________________
Please note whether the above restrictions are:
____ Not likely to change.
____Temporary From:_________To:____________
Date patient can return to work:______________
_______Without Restrictions
_______With Restrictions as noted above
Please attach copies of your clinical records on this patient. Use the space below for any additional comments you may have:
Date Report Completed:
______________________________
Signature of Physician:
______________________________
Physician Name:
______________________________
Address:
______________________________
Telephone:
______________________________
Specialty:
______________________________
Patient:____________________________________ SS #:_______________
Date Of Birth:_______________
Dear Doctor:
Please answer the following questions with regard to your patient's claim for Social Security disability benefits or Supplemental Security Income (SSI) and/or with regard to your patient’s claim for Long Term Disability (LTD). Please base your answers on how your patient's medical conditions affect his or her ability to function.
1.Nature, frequency and length of contact:
2.Please describe patient's symptoms (including patient's reports of pain, dizziness, etc.):
3.State all clinical findings and laboratory/test results (or enclose copy of same): Please link findings to specific limitations.
4.Diagnosis:
5.Treatment and response (including list of medications and their effect and side-effects):
6.Prognosis:
7.Has the patient's impairment lasted, or can it be expected to last, at least twelve months?Yes _____ No _____
8.Can the patient continuously stand for at least 6 of 8 hours?Yes _____ No _____ How long CAN the patient stand? ____________
9.Can the patient continuously sit upright for at least 6 of 8 hours?Yes ______ No ______ How long CAN the patient sit upright? ______
10.If the answer to either number 8 or number 9 is NO, why is the patient unable to sit or stand?11.Does the patient have to lie down during the day? Yes ______ No ______ If yes, please explain why:12.How many city blocks can the patient walk without stopping?
Please check the frequency that the patient can perform the following activities:
Never Occ. Freq. Const.
0-33% 34-67% 68-100%
Reach Above shoulder ______ ______ ______ _______
At waist level ______ ______ ______ _______
Below waist level ______ ______ ______ _______
Handling (gross motor) ______ ______ ______ _______
Fingering (fine motor) ______ ______ ______ _______
Feeling ______ ______ ______ _______
14. How many pounds can the patient frequently lift over an 8 hour period?_____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50
15. How many pounds can the patient frequently carry?____ Less than 5 _____5-10 _____11-20 _____21-50 _____over 50
16. Does the patient have any problems performing such functions as grasping, pulling, pushing, or doing fine manipulations with his or her hands? PLEASE BE SPECIFIC.17.Does the patient have any problems with the following movements? (Please indicate any applicable range of motion studies):Bending ______________________________________Squatting ______________________________________Kneeling ______________________________________Turning any parts of the body ________________________
18. Is the patient able to travel alone? Yes _____ No ______Why?
19. Are there any other factors affecting the patient's ability to work (e.g. exposure to fumes, gases; ability to tolerate heights; restriction of exposure to moving machinery)?20. If your patient complains of any pain, please indicate the nature and severity of the complaints and your opinion of the patient's credibility with respect to his or her complaints:If there is an objective basis for the patient's pain, give specific details for this basis (i.e. degenerative changes in the spine):21. Considering your diagnosis of the patient's condition and his/her prognosis, is the patient capable of returning to his/her past job?
Yes _____ No _____ State why or why not:
22. Considering the same factors, is there any work the patient is capable of? State why or why not:___________________________________________________________
Please note whether the above restrictions are:
____ Not likely to change.
____Temporary From:_________To:____________
Date patient can return to work:______________
_______Without Restrictions
_______With Restrictions as noted above
Please attach copies of your clinical records on this patient. Use the space below for any additional comments you may have:
Date Report Completed:
______________________________
Signature of Physician:
______________________________
Physician Name:
______________________________
Address:
______________________________
Telephone:
______________________________
Specialty:
______________________________
