Functional Capacity Evaluation Form

Capture a patient's medical background, lifestyle habits, and physical restrictions ahead of a functional capacity review. Built for physical therapists, occupational health providers, and rehab clinics.

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Full Name

Nombre

Apellido

Date of Birth

Gender

Male Female Non-binary Prefer not to say

Height (cm)

Weight (kg)

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Current Health Conditions

Medical History

Current Medications

Have you had any recent surgeries or hospitalizations?

Yes No Not sure

If yes, please provide details

Do you have any allergies?

Yes No Not sure

If yes, please specify

Do you smoke?

Yes No Occasionally

If yes, how many cigarettes do you smoke per day?

Do you consume alcohol?

Yes No Occasionally

If yes, how many drinks do you have per week?

Please list any physical limitations or restrictions you have

Please list any medications you are currently taking

Is there any additional information you would like to provide?

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