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Functional Abilities Form

Functional Abilities Form

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____ 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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