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FUNCTIONAL CAPACITY EVALUATION REPORT Injured Worker Details Claimant Name: Claim No: Date of Birth: Date of Injury: Nature of Injury: Pre Injury Occupation: Pre Injury Hours: Date of Report: Rehabilitation Provider Details Company Office Location and Address WorkCover Provider Site Number Consultant and Qualifications Phone Fax Email Signature

Employer Details (if applicable) Company Employer Contact Employer Role Phone Fax Email

Client Name:

Claim number:

BACKGROUND 1.1 Purpose of Assessment CLIENT NAME was referred for a Functional Capacity Evaluation (FCE) on XX/XX/XX 2012 by Case Manager Name (Position, The Company Name). The purpose of the Functional Capacity Assessment was to determine Mr Client’s current physical abilities to assist in identifying appropriate vocational options. The Functional Capacity Evaluation took place on XX/XX/XX at …….Office. 1.2 Reviewed Reports: The following reports were reviewed for the purpose of this assessment: 1.3 Presenting complaints: The following conditions were reported by CLIENT NAME: - . 1.4 History of Injury Mr X reported the following medical condition….. Mr X sustained an injury to his _____on _____ whilst…... At the time of the injury Mr X was _____________. Report mechanism of injury and events that occurred immediately thereafter. Overview outline of events in regards to ceasing work, seeking medical treatment etc . Current Symptoms: At the time of the assessment Mr X reported the following symptoms: Treatment for Compensable Condition: In terms of treatment to date, Mr X reported the following information: - Past Treatment: o - Current treatment: o X - Future Treatment: 1.5 Current Medical Certification: Mr X’s current medical certificate completed by his Nominated Treating Doctor, Dr XX on XX/XX/XXXX, states that he is currently certified unfit/fit for suitable duties from XX/XX/XXXX to XX/XX/XXX Lifting …..

CURRENT STATUS 2.1 Current Injury status CLIENT NAME is not/currently certified fit for suitable duties. Insert employment information/status if working. 2.2 Pain: CLIENT NAME rated his pain at the start of the assessment as X/10 (VAS). CLIENT NAME advised that his pain rating increased to X/10 during (list tasks that increased pain)….

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Client Name:

Claim number:

CLIENT NAME advised that his pain symptoms were aggravated by……. CLIENT NAME reported easing factors included………. 2.3 Medication CLIENT NAME stated that he takes the following medication on a regular basis:  . 2.4 Reported Functional Tolerances Posture Standing Sitting Walking Overhead reaching Reaching forward Stooping Squatting Kneeling Stairs Driving

Comments

RESULTS OF ASSESSMENT 3.1 General health Screening CLIENT NAME was asked a number of health screening questions prior to the commencement of the FCE to ensure that it was safe to complete the assessment. CLIENT NAME’s blood pressure was measured to be Diastolic/Systolic which is within Normal range.

3.2 Grip Strength CLIENT NAME advised that he is right hand dominant. CLIENT NAME’s grip strength was assessed as Xkg’s on the right and Xkg’s on the left (at position 2). When comparing to norms (for age and gender) his grip strength is considered higher/lower than average in his left hand (X%), and high/lower than average (X%) in his right hand.

3.3 Active Range of Motion

Trunk Flexion Extension Lateral Flex Rotation

R: L: R: L:

Normal Range 80 30 35 35 45º 45º

Functional Capacity Evaluation Report

Results

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Client Name:

Cervical Spine (neck) Flexion Extension Lateral Flex Rotation

Shoulder Flexion Extension Abduction Internal Rotation External Rotation

R: L: R: L:

45º 45º 45º 45º 90º 90º

R: L: R: L: R: L: R: L: R: L:

180º 180º 60º 60º 180º 180º 70º 70º 90º 90º

R:

90º

L: R: L: R: L: R: L: R: L:

90º 30º 30º 45º 45º 30º 30º 45º 45º

R: L: R: L:

135º 135º 0º 0º

Claim number:

Hip Flexion (knee extended) Extension Abduction Adduction Rotation Int/Ext

Knee Flexion Extension

NB: report other observations 3.4 - 3-minute step test Mr Client completed a 3 minute step test using a step height of 30cm. Mr Client was observed to maintain/unable to maintain the correct step rate of 90spm for the 3 minute duration. Ok

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Client Name:

Claim number:

Other observations – Heart rate one minute post assessment:

Mr Client’s fitness was assessed to be ______ compared to normative data/ 3.5 Lifting CLIENT NAME was assessed to be able to perform the following safe maximal lifts: - Lifting Xkg from floor to waist - Lifting Xkg from waist to waist - Lifting Xkg from waist to shoulder CLIENT NAME reported that he believed he would/would not be capable of lifting these loads on a repetitive basis. 3.6 Carrying CLIENT NAME was observed to carry the following weights over a distance of 20 metres: - Carry Xkg bilaterally - Carry Xkg in the left hand - Carry Xkg in the right hand 3.7 Manual Handling Ability CLIENT NAME was observed to have an understanding of safe manual handling techniques. During transfer and carrying activities, CLIENT NAME was observed to maintain a good body posture, keeping his trunk straight, and using his feet to turn his body around instead of twisting or rotating at his hips. During the lifting activities, CLIENT NAME was observed to keep the boxes close to his body, maintaining a neutral spine, and using his upper body strength to carry the loads as requested.

3.8 Postural Tolerance / Functional Task Results Task

Unlimited Tolerance

Reduced Tolerance

Tolerance < 3 mins

Unable/Not Recommended

Standing - Static Standing– Dynamic / Static Walking – even ground Walking – uneven ground Sitting (observed) Prolonged reaching above head-height Sawing Squatting Prolonged forward bending postures

3.9 Dynamic Activities

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Client Name:

Claim number:

Walking – CLIENT NAME reported he is able to walk for…..before experiencing an increase in knee pain. CLIENT NAME was observed to walk on even/uneven ground with a abnormal/normal gait as a steady pace. Report on pain tolerances. Pushing/pulling – CLIENT NAME reported …… with pushing/pulling. He/she was observed to push/pull (insert load/item) for Xmins. Insert symptoms and observations.

SUMMARY/RECOMMENDATIONS CLIENT NAME presented with the following compensable medical conditions: 4.1 Functional Abilities Functional assessment results indicate that given normal rest breaks and allowing for postural changes during the workday, CLIENT NAME is able to perform the following tasks, over an 8-hour workday without restriction:  Occasional Tasks: Provided frequent postural changes are permitted over an 8-hour workday, CLIENT NAME is safe to perform the following with minimal risk of symptom aggravation:  Limited Tasks: CLIENT NAME is assessed as safe to perform the following tasks for periods of less than 3 minutes and for minimal periods over an ?-hour workday (no more than 3 times an hour).  Tasks to be avoided: (considered contra indicative given injury and biomechanical concerns): Results of the FCE indicate that CLIENT NAME should avoid the following actions and movements in future employment related activity:  4.2 Test Performance Detailed overview of assessment and observations made. Frank participated in a Functional Capacity Exam to observe his performance in specific functional tasks which may be associated with his work and return to work plan. Frank performed all upper body task adequately with no complaints. Although Frank grimaced and expressed pain when performing lower limb/knee based activities. Examples include, frank was unable to perform more than 3 semi-squats before pain halted activity, frank was also unable to maintain a constant step rate and unable to complete the full 3 minute term. 4.4 Recommendations

Workplace/Vocational - Reduce franks need to pick up heavy objects to avoid bending at knee and back strain - Reduced capacity to weight bear with additional weight - Different job tasks, maybe supervisor/ managing/ admin role nothing to physical - May require extra training on computer and how to perform new tasks

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Client Name:

Claim number:

- Send to DES provider to guide job seeking Treatment and Recovery - Wein off tramadol to allow for appropriate OM

- Continue with physio and educate on the benefits of performing the task Alted Psychosocial/Other - Increase motivation and interest levels - Catching up with ‘mates’ again so that he feels apart of the team and valued

Should you have any queries relating to information contained within this report please do not hesitate to contact the undersigned on my telephone number or via email …… . Kind regards

My Name My Profession My Title

Cc

Mr Injured Worker (Injured Worker) DES Employment Consultant Dr NTD (NTD) Mr Big Boss (Manager, Company Name) Ms Case Manager (Case Manage, Insurers name) File Copy

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