Functional capacity evaluation form - WellSpan Health - wellspan 2026

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The document provides detailed information regarding the Functional Capacity Evaluation (FCE) process at Wellspan Rehabilitation, including preparation guidelines, medical history forms, and instructions for participants. It emphasizes the importance of arriving on time, bringing necessary documentation, and adhering to health precautions prior to the evaluation. Additionally, it includes a pain scale for participants to assess their pain levels during the evaluation.

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Click ‘Get Form’ to open the Functional Capacity Evaluation form in the editor.
Begin by filling out your personal information in the 'Information/Medical History' section, including your name, date of birth, and contact numbers.
Proceed to describe your current conditions and chief complaints. Be specific about why you are being referred for this evaluation.
Complete the medical history questions regarding previous treatments and any other healthcare providers involved in your care.
Fill out the 'Clinical Tests' section by checking any tests you have undergone in the past year.
In the 'Medications' section, list any prescription or nonprescription medications you are currently taking.
Provide details about your social history, including marital status and living situation, as well as any cultural concerns that may affect your care.
Finally, review all sections for completeness before saving or printing the form to bring to your appointment.

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How do you evaluate functional capacity?

What is a functional capacity evaluation? A FCE is a series of tests that help evaluate your physical abilities. The tests have you pull, push, lift and complete other tasks that relate to your job duties. Your physical therapist observes your performance as you complete these tests and records this data in a report.

What is a functional capacity assessment?

A Functional Capacity Assessment is a comprehensive assessment of a persons capability across a range of daily activities and environments. It examines how well youre managing your everyday tasks, like taking care of yourself and handling things around the house.

What is an example of a functional assessment?

What happens if you get your functional capacity evaluation test results and you find out youve failed? Technically, you cant really fail your FCE exam. You may get FCE test results that state youre not fit enough to resume working.

How to complete a functional capacity assessment?

What Does a Functional Capacity Assessment Involve? Initial Consultation. The assessor will discuss your medical history, daily routine, challenges, and current supports. Practical Assessments. Interviews with Carers and Family Members. Report and Recommendations.

What to expect at a functional capacity test?

Functional Testing: You will undergo physical tests that involve pulling, pushing, lifting, and carrying materials. Dexterity: The healthcare professional will test your physical capacity for actions such as squatting, walking, kneeling, docHubing, standing, balancing, crawling, bending, sitting.

functional capacity evaluation form template

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What is included in a Functional Capacity Evaluation?

A functional capacity evaluation (FCE) is a set of tests that are used to identify a persons physical skills, functional capabilities, activity endurance, and work tolerances.