Physician Statement Of Physical Capabilities
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Physician Statement Of Physical Capabilities Form. This is a West Virginia form and can be use in Workers Comp.
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Tags: Physician Statement Of Physical Capabilities, West Virginia Workers Comp,
Physician Statement
Of Physical Capabilities
Claimant Name:
Return completed form to:
BrickStreet Mutual Insurance
P.O. Box 3151
Charleston, WV 25332-3151
Claim Number:
Date of Injury:
Please complete this form after your examination of the patient. Indicate the patient’s restrictions, if any,
including modified hours, duties, environmental factors and any other information pertinent to
this employee’s healthy recovery and possible early return to work.
Medical Diagnosis:
In an eight-hour workday, how many hours can this employee:
Sit
1
2
3
4
5
6
7
8
Continuously
With Rests
Stand
1
2
3
4
5
6
7
8
Continuously
With Rests
6
7
8
Continuously
With Rests
Walk
1
2
3
4
5
In a given day, how many total hours can this employee work?
Upper Extremities
Which hand is dominant?
Right
Left
Can the employee perform these repetitive actions?
Yes
No
Lower Extremities
Can the employee perform repetitive actions to operate foot
controls or motor vehicles?
Yes
Right
Left
No
Simple grasping
R
L
R
L
Pushing and pulling
R
L
R
Right
Left
Simultaneous
Yes
No
L
Lifting / Carrying
10 lbs. or less
11 – 20 lbs.
21 – 40 lbs.
41 – 60 lbs.
61 – 100 lbs.
Pushing / Pulling
13 – 25 lbs.
26 – 40 lbs.
41 – 60 lbs.
61 – 100 lbs.
100+ lbs.
Comments:
Please indicate the extent to which the employee can perform the following:
(N = Never, O = Occasionally, F = Frequently, C = Continuously)
N
O
F
C
Activity
N
Bend
Squat
Kneel
Twist / Turn
Climb
Crawl
Reach Above Shoulder
Type / Keyboard
Driving
Automatic
Standard
Physician Name:
Date released with above restrictions:
Physician Signature:
O
F
C
Physician Telephone:
Date released for full-duty work:
Date:
Updated: 10/08
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