Get Functional Capacity Evaluation Form - Wellspan Health - Wellspan

This guide will assist you in completing the Functional Capacity Evaluation Form from WellSpan Health online. By following the detailed steps provided, you can ensure that all necessary information is accurately provided for your evaluation.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Functional Capacity Evaluation Form and open it for editing.
2. Begin filling in your personal information in the 'Information/Medical History' section. This includes your name, date of birth, and contact numbers. Ensure all entries are accurate and up-to-date.
3. Provide details regarding your current conditions and chief complaints. Describe briefly why you have been referred for this evaluation, when the problem began, and previous treatments you have received.
4. Complete the clinical tests history by checking all relevant tests you have undergone in the past year. This helps provide context for your evaluation.
5. In the medications section, indicate whether you are taking any prescription or non-prescription medications. List these medications if applicable.
6. Fill out the social history, including marital status, living situation, and education level. Note any cultural or religious concerns that may affect your care.
7. Review your functional status and activity level, checking any difficulties you face in daily activities. Provide percentage estimates for your current ability in various activities.
8. Complete the social/health habits section by detailing your smoking and alcohol consumption habits, along with any exercise routines you follow.
9. Assess your medical/surgical history, marking any relevant past conditions or surgeries you've experienced.
10. Provide vocational information, including your current work status, job title, and a brief description of your job duties and physical demands.
11. Finish by signing the form. Ensure you have filled out all fields completely as incomplete forms may require rescheduling of your evaluation.
12. Once completed, save any changes made to the form, and consider downloading, printing, or sharing it as needed.

Take a moment to complete the Functional Capacity Evaluation Form online now.