Assessment Of Residual Functional Capacity
PATIENT NAME: BIRTH DATE: AGE:
SOCIAL SECURITY NO: DATE OF DISABILITY:
TO WHOM IT MAY CONCERN:
The undersigned has treated or examined the above patient and has determined that he or she has the capacities and limitations described below at the time of discharge. Such recommendations represent limitations which he or she should not exceed and arise from the following diagnosis(es):
Diagnosis #1: Diagnosis #2:
WORK CAPACITIES
STANDING, number of hours at one time
SITTING, number of hours at one time...
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