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Functional Capacity Evaluation Form Template

Assess Patient Abilities with a Comprehensive FCE Template

Determining a patient's physical capabilities can be challenging, but our Functional Capacity Evaluation Form helps you streamline the assessment process. This template is perfect for clinicians and healthcare professionals looking to accurately evaluate physical abilities and limitations stemming from medical conditions. Enjoy clear documentation, improved patient communication, and easy customization to fit your needs, all while ensuring compliance with accessibility standards. Start enhancing your evaluations with this user-friendly template today.

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Full name
Date of birth
Phone number
Email address
Employer or organization
Job title or role
Evaluation date
Current work status
Working full duty
Working with restrictions
Off work
Unemployed
Student
Retired
Other/Not applicable
Date of injury or symptom onset
Body region(s) affected
Diagnosis or primary condition
Are you currently receiving treatment?
Yes
No
Current pain level (0-10)
Worst pain in the past 7 days (0-10)
How often do you experience pain?
Never
Rarely
Sometimes
Often
Always
Walking 15 minutes continuously
Very difficult
Difficult
Neutral
Easy
Very easy
Standing 30 minutes continuously
Very difficult
Difficult
Neutral
Easy
Very easy
Sitting 30 minutes continuously
Very difficult
Difficult
Neutral
Easy
Very easy
Maximum safe lift from floor to waist
Unable
Up to 10 lb (4.5 kg)
11-20 lb (5-9 kg)
21-30 lb (10-14 kg)
31-40 lb (14-18 kg)
41-50 lb (19-23 kg)
51+ lb (23+ kg)
Not assessed
Carry capacity for 50 feet
Unable
Up to 10 lb (4.5 kg)
11-20 lb (5-9 kg)
21-30 lb (10-14 kg)
31-40 lb (14-18 kg)
41-50 lb (19-23 kg)
51+ lb (23+ kg)
Not assessed
Handling small objects (e.g., buttons, coins)
Very difficult
Difficult
Neutral
Easy
Very easy
Likelihood of returning to usual work in the next 4 weeks
Very unlikely
Unlikely
Neutral
Likely
Very likely
Recommended work capacity category
Sedentary
Light
Medium
Heavy
Very heavy
Not determined
Work restrictions recommended (select all that apply)
Assistive devices used and any precautions to observe
Participant typed name
Date
I consent to the Functional Capacity Evaluation and authorize sharing the results with the referrer/employer named above
Yes
No
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Paper art illustration depicting a functional capacity evaluation form template for FormCreatorAI article.

When to use this form

Use this capacity form when you need objective, job-matched data to guide return-to-work, rehab, or disability decisions. It helps physical and occupational therapists, case managers, and employers evaluate lifting, carrying, range of motion, and endurance in a controlled setting. Run it after a musculoskeletal injury, before placing an employee in a physical role, or to verify progress mid-rehab. For fuller context, pair results with a General health appraisal form and a Head to toe assessment form. The outcome is a clear set of abilities, limits, and recommended restrictions or accommodations that keep the worker safe and productive.

Must Ask Functional Capacity Evaluation Questions

  1. What essential job tasks and physical demands must you meet (lift, carry, push/pull, reach, stand, sit), and how often?

    This aligns testing with real job needs and keeps the assessment relevant. Specifying frequency and weights makes results actionable for duty matching and ergonomics.

  2. What is your current maximum safe lift, carry, and push/pull capacity, including posture and repetition tolerance?

    Quantifying capacity sets clear thresholds for safe work. Noting posture and reps prevents overestimation based on a single effort.

  3. How long can you safely sit, stand, and walk before you need a rest break, and what recovery time do you need?

    Endurance and recovery guide shift planning and phased returns. If fatigue is a concern, tracking patterns with a Sleep tracker form can validate recommendations.

  4. Where did you feel pain or symptoms during testing, how intense were they, and what activities triggered or relieved them?

    Detailed symptom mapping connects tasks to risk and informs treatment. Pairing notes with a Symptom screening form supports consistent follow-up and documentation.

  5. What accommodations, assistive devices, or work restrictions do you recommend to perform tasks safely?

    Clear guidance helps employers implement reasonable adjustments and comply with policy. It also sets expectations for workers' comp, case managers, and clinicians.

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