Functional capacity evaluation form - WellSpan Health - wellspan 2026

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

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