Functional Capacity Assessment
C. MANIPULATIVE LIMITATIONS:
Unlimited Limited
Handling (gross) G G
Fingering (fine) G G
Feeling (skin receptors) G G
D. MENTAL LIMITATIONS:
Unlimited Limited
Understanding G G
Remembering G G
Sustained concentration G G
Following through on instructions G G
Decision making G G
Responding appropriately to workplace pressures G G
Receiving supervision G G
Relating to co-workers G G
E. VISUAL/COMMUNICATIVE LIMITATIONS:
Unlimited Limited
Acuity (near/far); Depth; Color; Field G G
Hearing G G
Speaking G G
F. NON-PHYSICAL EXERTION LIMITATIONS:
Pain (frequency; degree; objective signs)
Environmental restrictions (exposure to dust, fumes, smoke, heights, heat/cold, noise; other)
Rest periods (frequency/duration)
Side effects of medication
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