1. health and fitness

Fax # 905-577-8379
FUNCTIONAL ABILITIES FORM (Non Occupational)
Employee Name: _______
_______ Occupation: ___
___ Department: ___
___
By signing below, I am authorizing any health professional, now treating me, for an injury or illness to provide me, my employer and HHSC
Insurance Carrier with information about my functional abilities for a timely return to work.
Employee’s Signature: _________________________________
Date: ____________________
Section A: HEALTH CARE PROVIDER’S STATEMENT
Date patient expected to recover or return to work: ____________________________________________________
Is rehabilitative treatment required?  Yes  No
Choose one:
____
____
____
A. Employee is/was fit to work without restrictions on: ____________________ (date)
B. Employee is/was fit to work with restrictions: _____________________(date) (please complete Section B)
C. Employee is unfit to work. Prognosis for  Full recovery  Possible return to modified duties:____________
Hours:
Full hours □
Modified/Graduated hours □
Recommendations:______________________________
Section B: FUNCTIONAL ABILITIES (check only those that apply)
SITTING/STANDING/WALKING
Seldom
(not daily)
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Minor
(up to 1 hr/day)
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Frequent
(1-3 hr/day)
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Major
(> 3 hr/day)
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Comments
Sitting
Standing
Walking
Crawling
LOWER BODY
Kneeling
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Crouching/Squatting
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Bending
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Twisting
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Stair Climbing
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Ladder Climbing
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UPPER BODY
L R Both
L R Both
L R Both
L R Both
Push/Pull against resistance
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Carrying
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Gripping
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Keyboarding
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Reaching at/below shoulder level
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Reaching above shoulder level
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Handling
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Fine Finger Movement
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LIFTING FLOOR TO WAIST
L R Both
L R Both
L R Both
L R Both
Less than 2kg
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2kg to 5kg
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5kg to 10 kg
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□ □ □ Note: HHS lift guideline is a max of 11.4kg
Greater than 10kg
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LIFTING WAIST TO SHOULDER
L R Both
L R Both
L R Both
L R Both
Less than 2kg
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2kg to 5kg
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5kg to 10kg
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□ □ □ Note: HHS lift guideline is a max of 11.4kg
Greater than 10kg
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LIFTING ABOVE SHOULDER
L R Both
L R Both
L R Both
L R Both
Less than 2kg
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2kg to 5kg
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5kg to 10kg
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□ □ □
□ □ □
□ □ □ Note: HHS lift guideline is a max of 11.4kg
Greater than 10kg
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OTHER RESTRICTIONS - If Applicable
□ Chemical exposure:: ____________________________________________________________
□ Travel to work: □ Ability to use Public Transit □ Ability to Drive
□ Operating Motorized equipment: ______________________________________________________________________
□ Potential side effects from Medication: ______________________________________________________________________
□ Exposure to vibration: ______________________________________________________________________
Additional Comments and or Restrictions not listed:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Restrictions in place for _________________________________
Date of Next Appointment_________________________
Name of Health Care Provider (please print)_____________________________________ Specialist?  Yes  No
Address (number, street, city, province, postal code)
Telephone Number (
)__________________ Fax Number (
)_________________________
_______________________________________________
Health Care Provider’s Signature
_________________________________
Date (month, day, year)
PLEASE FAX THE COMPLETED FORM TO 905-577-8379
The hospital will reimburse costs for the completion of this form. The Physician’s office can directly bill Hamilton
Health Sciences. Please forward ORIGINAL receipts, within twelve months of the receipt date, to:
Hamilton Health Sciences
Chedoke, Ewart 218
PO Box 2000
Hamilton, ON
Canada L8N 3Z5
REFERENCE:
Reaching:
movement of the elbow away from the body
Stooping:
sustained bending at the waist/hips with straight knees
Bending:
dynamic movement at the waist/hips with straight knees
Crouching:
sustained forward bend at the hips with knee flexion
Squatting:
dynamic forward bending at the hips with knee flexion
Repetition: refers to performing a task or series of motions over and over again with little variation. When motions
are repeated frequently (every few seconds) for prolonged periods (several hours, a work shift), fatigue and strain of
the muscle and tendons can occur because there may be inadequate time for recovery. Repetition often involves the
use of only a few muscles and body parts, which can become extremely fatigued while the rest of the body is little
used (Kilbom, 1994).