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Functional Abilities Form
____
NO _____
Is the employee capable of returning to work immediately without restrictions?
YES ___ NO ___
If no, please complete the next section
GENERAL
COMMENTS/SPECIFIC
LIMITATIONS
CABABILITIES
Walking
Short distances only ___
As tolerated __
Other __________
Standing
Less than 15 min. ____
Less than 30 min. __
As tolerated ___
Other __________
Sitting
Less than 30 min. ____
Less than 1 hour ___
As tolerated ___
Other __________
Lifting floor to waist
Less than 10 kg....
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