Assessment of Work Abilities Form

Claim Number:

NOTE TO BE MEDICAL CARE PROVIDER:

This assessment provides accommodation to ill and/or injured employess.

1. Do not provide diagnosis, treatment or return to work data.

2. This form may shared with your patient's supervisor or other non-medical staff at.

3. Billing - The completion of this form can be billed to SGI as a 20 minute subsequent visit.

WORK ABILITIES:

Demand	Fully Able	Modified Abilities	Select Frequency	Demand	Fully Able	Modified Abilities	Select Frequency
Twist/Turn				Shoulder
Bend				Wrist
Stairs				Grip
Ladders				Driving
Walk				Judgement
Sit				Memory
Crouch/Squat/Kneel/Crawl				Public Contact
Stand				Multiple Tasks
Pulling				Concentration
Pushing				Able To Provide Supervision
Carrying(Load/Distance)				Able To Receive Supervision
Lift Floor To Waist				Sight
Lift/Reach Waist To Shoulder				Hearning
Lift/Reach Overhead				Speech
Neck				Operating Machinery
Work Hours				Operating Motor Vehicles
Work Shifts				Working at Heights
*Frequency – 1% Rare, 2-5% Infrequent, 6-33% Occasional, 34-66% Frequent, 67-100% Constant

Formal Functional Test Completed:

Matheson

Work Well

Other

Environmental conditions that should be avoided:

Regulated Inside Climate

Outside

Dust

Latex Gloves

Chemicals

Other

Medical aids of personal protective equipment required as a result of the condition?

Yes

This employee will need to attend appointments at the following intervals:

Days

2 to 4 Weeks

4 to 6 Weeks

6 to 8 Weeks

8 to 10 Weeks

> 10 Weeks

Long Term

Permanent

Care Provider Name:

Phone Number:

Fax Number:

Care Provider Signature:

Date: