IME,Inc.
211 Beaumont
Traverse City,
Michigan MI 49684
Tel: (800)
968-4637
(800) 968-4637 |
Independent Medical Evaluations, Inc.
A National Company Providing |
|
FUNCTIONAL CAPACITIES EVALUATION RE:
Client:_________________________________
Claim #______________________
Note:
In terms of an 8-hour workday, "occasionally" equals
1% to 33% to "frequently", 34% to 66%,
"continuously", 67% to 100%. 1.
Assuming
normal breaks and lunch hour in an 8-hour day, employee can:
(circle full capacity for each activity)
If not eight hours, how many and when?_______________________________________ 2.
Employee able to :
Not at all
Occasionally
Frequently
Continuously a.
Bend/Stoop_________
b.
Squat c.
Crawl d.
Climb
- Height______________ e.
Reach
above shoulder level________ f.
Crouch g.
Kneel h.
Balance i.
Push/Pull___________
Comments:
(If appropriate, not frequency per hour or day) Client:_______________________
3.
Employee
can carry: Never Occasional Frequently Continuously
4.
Employee
can lift:
Never Occasional Frequently Continuously
5.
Employee
can use feet for repetitive movements as in operating foot
controls: RIGHT:
Yes
No
LEFT:
Yes
No BOTH:
Yes
No 6.
Employee
can use hands for repetitive action such as: Simple
Firm
Fine Grasping
Grasping
Manipulating RIGHT: Yes No
Yes
No
Yes
No LEFT:
Yes No
Yes
No
Yes No 7.
Employee
can use head and neck in: Static Position
Frequent
Frequent Rotating Yes
No
Yes No
Yes No 8.
Restriction
of activities: For example, being around moving machinery, driving
automotive equipment or any other restrictions required by the
physical impairment. Client:_________________ Based
upon these limitations and restrictions, is this patient able to
work in general:
Yes
No Signature
of Physician__________________________
Date________________
I
hereby authorize___________________________________
to release this
Functional Capacities Evaluation to Independent Medical
Evaluations, Inc.
Independent Medical Evaluations, Inc.
Corporate Office
IME,
Inc. Home | Legal
Nurse Consultants
Independent Medical Evaluations (IME), Inc.
Company Services Legal Disclosure:
Independent Medical Evaluations - IME , Inc. provides expertise in many legal and medical situations including the following: Independent Medical Evaluation, Independent Medical Exam, Independent Medical Examinations, Impartial Evaluations, Physician Panel, Permanent Partial disability Examination, Medical Fraud Investigation, Medical Discovery, Expert Witness, Expert Witnesses, Medical-Legal Experts, Legal Nurse Consultant, Depositions, Live Testimony, Legal Nurse Consulting, Tort State, Personnel Injury, Defense Exams, Legal Nurse Consultants, Plaintiff Exams, Criminal Medical, Civil Medical, No Fault / Liability, Medical Claim, Medical Consultant, Insurance Medical Claim, Workers Compensation, Impairment Evaluations, Unbiased Medical Opinion, Disability, Medical-Legal Professionals, Certified Independent Medical Examiners, American Board of Independent Medical Examiners, SEAK, American Academy of Disability Evaluating Physicians (AADEP), Work Injuries, Auto Injuries, Car Accident Claims, Family Medical Leave (FMLA), Auto No Fault, Independent Medical Opinion (IMO), Medical Review, File Review, Medical Chart Review, Peer Review, Standards of Care, Malpractice, Medical Case Discovery, Medical Investigation, Long Term / Short Term Disability, Sickness and Accident, Early Assessments, Medical Illustrations, Auto Tort, Panel IMES, DNA Testing, Biomechanical Evaluations, Fitness for Duty, Physician Panel, Discovery, IME, Medical Malpractice, Compensibility, Management, Return To Work Issues, End Point, Maximum Medical Improvement, Orthopedics, Orthopedic Surgeon, Neurologist, Neurology, Physical Medicine, PMR, Psychiatry, Psychiatric, TMJ Specialist, Chiropractic, Chiropractor, Neurosurgeon, Neuropsychologist, Neuropsychology Testing, Plastic Surgeon, Oral Surgeon, ABIME, Disability Consultants, Psychologist, Psychology, MMPI, Nationwide Medical, Employer Health, Drug Testing, NIDA Labs and more. For
More Information About Independent Medical Evaluations, Contact
Our Corporate Office:
|
