Pre-Employment Functional Assessment

Candidate Details

Employer: Position:

First Name: Surname:

Address:

Suburb: Postcode:

Mobile #: Home/Work #:

Email:

Date of Birth: / / Age: _ Gender: Male Female

NB: Do not commence the Functional Capacity Evaluation unless the three boxes below are ticked.

Pre-Functional Capacity Evaluation Questions (Consultant to complete) Y

e
s

Photo Identification checked

Consent Form Declaration signed by Candidate

Medical Questionnaire completed by Candidate

Blood Pressure
The candidate’s blood pressure (BP) must be 149 / 99 or less and the resting heart rate (HR) must less than 100
bpm to begin the Functional Capacity Evaluation. There are a maximum of five trials to record a resting BP less than
149 / 99 and resting HR less than 100. The lowest Systolic and Lowest Diastolic reading across the five trials can be
used. If after five trials the resting BP is greater than 149 / 99 or the lowest resting HR is greater than 99, please
refer the candidate for GP clearance. The functional assessment cannot be performed unless APM receives GP
clearance.

Test No. 1 No. 2 No. 3 No. 4 No. 5

Seated / Seated / Seated / Seated / Seated /
Supine Supine Supine Supine Supine
Resting BP mmHg

Resting Heart
Rate Beats per
minute

Please see Blood Pressure Comment Guidelines at the end of the assessment.

Medical History Review

Discuss Pre-Screening Questionnaire: Yes

Mark areas of concern/previously reported injuries and give details, including (a) The nature of the issue, (b) when
the issue occurred, and (c) if the issue has been resolved.

Weight & Body Mass Index

Measure Result
Height (cm) (cm)
Weight (kgs) (kgs)
BMI Calculation: Weight (kgs) / Height (cm) x Height (cm) x 10,000

BMI Rating (Tick):

<18.5 Underweight 18.5 - 24.9 Normal 25. – 29.9 Overweight >30 Obese
Comments:
Range of Motion

Cervical/Neck:
Movement Expected Cervical/Neck Range of Motion Result
Range
(degrees)
Flexion 0-45
Normal Abnormal
Extension 0-45

Lateral Flexion If ABNORMAL provide comments:

- Right 0-45
- Left 0-45

Rotation
- Right 0-90
- Left 0-90

Thoraco-Lumbar Spine:

Movement Expected Thoraco-Lumbar Spine Range of Motion

Range Result
(degrees)
Forward Flexion 0-90
Normal Abnormal
Extension 0-30

Lateral Flexion If ABNORMAL provide comments:

- Right 0-35
- Left 0-35

Rotation
- Right 0-45
- Left 0-45

Lower Limb

Movement Expected Hip Range of Motion Result

Range
(degrees)
Hip
Normal Abnormal
Flexion
- Right 0-90
- Left 0-90 If ABNORMAL provide comments:

Extension 0-30
- Right 0-30
- Left

Abduction
- Right 0-45
- Left 0-45

Adduction
- Right 0-30
- Left 0-30

Internal/External
Rotation
- Right 0-45
- Left 0-45
 Movement Expected Knee Range of Motion Result
Range
(degrees)
Knee
Flexion Normal Abnormal
- Right 0-
- Left 13
5
0-
13
5
If ABNORMAL provide comments:
Extension
- Right 0-
- Left 13
5
0-
13
5

Movement Expected Ankle Range of Motion Result

Range
(degrees)
Ankle
Dorsiflexion Normal Abnormal
- Right 0-20
- Left 0-20
Plantar Flexion If ABNORMAL provide comments:
- Right 0-45
- Left 0-45

Forefoot
Inversion
- Right 0-35
- Left 0-35
Eversion
- Right 0-15
- Left 0-15

Upper Limb

Movement Expected Shoulder Range of Motion Result

Range
(degrees)
Shoulder
Flexion Normal Abnormal
- Right 0-180
- Left 0-180
Extension If ABNORMAL provide comments:
- Right 0-60
- Left 0-60

Abduction
- Right 0-180
- Left 0-180
Adduction
- Right 0-45
- Left 0-45

Internal Rotation
- Right 0-70
- Left 0-70
External Rotation
- Right 0-90
- Left 0-90
 Movement Expected Elbow Range of Motion Result
Range
(degrees)
Elbow
Flexion Normal Abnormal
- Right 0-
- Left 15
0
0-
15
0
If ABNORMAL provide comments:
Extension
- Right 0-
- Left 15
0
0-
15
0

Movement Expected Wrist Range of Motion Result

Range
(degrees)
Wrist
Flexion Normal Abnormal
- Right 0-80
- Left 0-80
If ABNORMAL provide comments:
Extension
- Right 0-70
- Left 0-70

Radial Deviation
- Right 0-20
- Left 0-20

Ulnar Deviation
- Right 0-30
- Left 0-30

Movement Digits Range of Motion

Result
Digits
Normal Abnormal
Full Fist
- Right
- Left
If ABNORMAL provide comments:

Full Wide Hand

- Right
- Left

Thumb to
finger
Opposition
- Right
- Left
Strength, Flexibility, Core Strength / Stability, Neurological Testing, Balance
Upper Limb testing

Test Score Comments

(If necessary)
Extensor Compartment Test Right & Left Circle strength against
resistance achieved
The wrist extensor compartment test assesses
any tenderness around the muscles and tendons 1 = Minimum strength
that may act as a precursor to epicondylitis of the 3 = Resistance against
elbow or “Tennis Elbow.” Tennis elbow is an
overuse syndrome or tendonitis involving the gravity 5 = maximum
region of the lateral humeral epicondyle. strength

Right: 1 2 3 4 5
Left: 1 2 3 4 5

Pain reported
Yes No

Shoulder Joint Muscle / Tendon Test

“Empty Can Test”
Negati
- Negative: Pressure exerted with no pain
or restriction ve

- Positive: Pain or restriction present Positi

during pressure
ve

Shoulder Stability “Push-Up Test” Circle level achieved

1 = Standing wall push-up Right: 1 2 3

2 = Push-up on knees Left: 1 2 3

3 = Full push-up on toes Pain

reported Yes

No

Abdominal Strength (Sit-up Test)

Performance Abdominal Strength

Able to perform abdominal sit-up with knees bent and hands behind neck & elbows Excellent
to touch knees
Able to perform abdominal sit-up with knees bent and arms folded across Good
chest and elbows to touch knees
Able to perform abdominal sit-up with knees bent and arms out straight & elbows Average
to touch knees
Unable to perform abdominal sit-up Poor
Back/Hamstring Flexibility (Sit & Reach Test)
● Knees straight, legs and heels flat on floor, feet 90 degrees
● Reaching/bending forward, hands together
● Measure in (cm) with ruler, zero is fingertips to toes

Males Females Circle Score Achieved

> +27cm > +30cm Excelle
nt
+17cm to +27cm +21cm to +30cm Good
+6cm to +16cm +11cm to +20cm Above Average
0 to +5cm +1cm to +10cm Averag
e
-8cm to -1cm -7cm to 0 Below Average
-19cm to -9cm -14cm to -8cm Poor
< -20cm < -15cm Very Poor

Core Strength & Stability (Bilateral Integration Test, Balance, Stability)

Performance Circle Score Achieved

Able to maintain steady balance against strong push Good
Able to maintain balance against some resistance Avera
ge
Loss of balance or unsteady against resistance Poor
Unable to perform test with no resistance Very Poor

Slump Test (Neural Canal Testing)

● Sit on chair or bed and extend knee

● Plantar or dorsi flex foot — Positive if any pain or discomfort in the neural canal
● Lower leg, tuck chin to chest and slump forward — Positive if any pain or discomfort in the neural canal
● Combine both by extending knee, slump forward, plantar or dorsi flex foot — Positive if any pain or discomfort
in the neural canal
● Ask candidate to report pain or discomfort then repeat for other leg

Negative Signs (no issues identified) Positive Signs (issues identified)

If the slump test is Positive please detail issues identified:

Balance
To determine the ability to maintain effective balance, body awareness and control

Romberg Double Leg Balance Test (Eyes closed for 30 seconds)

Instructions: With shoes off (ideally), stand legs straight and together with heels and big toes touching. Keep arms
flat by side and eyes closed. Balance for 30 seconds.

Criteria to stop test: Loss of balance, significant sway, feet move on floor, feet move apart, knees bend, arms move
away from side, or eyes open

Pass: Yes No
Cardiovascular Fitness (Three-Minute Step Test)

Step height of 300 mm, metronome at 96bpm. Subject steps for three minutes then immediately stops, sits down and
remains still for one minute while recovery HR is measured over the full one minute of recovery. For the one-minute
recovery, record the HR every 15 seconds and calculate the average HR over the last one minute of recovery by
dividing by four.

Stop the step test when the heart rate exceeds 85% of the maximum age predicted cut off or if you observe or the
candidate reports shortness of breath, chest pain, dizziness or any other pain or discomfort.

Age predicted max HR: (220 – age)

85% max HR:

3 Minute Step Test Heart Rates:

HR 30sec 1 min 1.30 min 2 min 2.30 min 3 min

Time prior
to test
HR

1 Minute Recovery Heart Rates and Average:

15 Sec 30 sec 45 sec 1 min Average

Time Recovery HR
HR

Results

Age (yrs) <26 26 - 35 36 - 45 46 - 55 56 - 65 >65

Male
Excellent 78 or less 80 or less 82 or less 86 or less 85 or less 87 or less
Good 79 - 89 81 - 89 83 – 96 87 – 97 86 – 97 88 – 96
Above Average 90 - 99 90 - 99 97 – 103 98 – 105 98 – 103 97 – 103
Average 100 – 105 100 – 107 104 – 112 106 – 116 104 – 112 104 – 113
Below Average 106 – 116 108 – 117 113 – 119 117 – 122 113 – 120 114 – 120
Poor 117 – 128 118 – 128 120 – 130 123 – 132 121 – 129 121 – 130
Very Poor 129 or 129 or 131 or 133 or 130 or 131 or
more more more more more more
Female
Excellent 84 or less 87 or less 89 or less 93 or less 94 or less 89 or less
Good 85 – 98 88 – 99 90 – 102 94 – 104 95 – 104 90 – 102
Above Average 99 – 108 100 - 111 103 – 110 105 – 115 105 – 112 103 – 115
Average 109 – 117 112 – 119 111 – 118 116 – 120 113 - 118 116 – 122
Below Average 118 – 126 120 – 126 119 – 128 121 – 129 119 – 128 123 – 128
Poor 127 – 140 127 – 138 129 – 140 130 – 135 129 – 139 129 – 134
Very Poor 141 or 139 or 141 or 136 or 140 or 135 or
more more more more more more

Score:
Excellent Good Above Average Below Poor Very Poor
Average Average

Postural Tolerance and Manual Handling

PLEASE COMPLETE THE SEPARATE POSTURAL TOLERANCE AND MANUAL HANDLING TEMPLATE AND
ADD TO THIS SECTION OF THE FUNCTIONAL ASSESSMENT.
Summary
 Assessment Results

The information provided is based on the findings on the date of assessment.

The Pre-Employment Assessment results detail the following restrictions and/or recommendations which are relevant
to the proposed role for this candidate:

Restrictions:

Recommendations for improvement within the job role which should not directly impact performance:

Candidate would benefit from: (Tick only if applicable)

Monitoring blood pressure with own GP

Reducing weight to improve body mass index (BMI)
Improving cardiovascular fitness
Quitting smoking to improve general health and reduce cardiovascular disease risk
Improving abdominal strength
Improving back and hamstring flexibility
Improving core strength and stability

Medical History:

List injuries and operations (current and prior), indicating the date of the issue, if the issue has resolved and if it is
likely to affect the candidate in the proposed position

Facts Sheets: (Please tick facts sheets provided)

Facts sheets are designed to provide candidates with health education to address specific issues identified in the
assessment.
Posture, Back Care & Manual Handling Diabetes
Alcohol Diet
Blood Pressure Smoking
Cholesterol Exercise Weight
Management
Cardiovascular
Disease

Consultant Name: Signed: Date: / /

 Summary Comment Guidelines
Please use the comment guidelines below for the Summary Report. Detail any other comments you feel are necessary.

Issue Restriction Comment Recommendation Comment

BP: 140 / 90 to 149 / 99 N/A Would benefit from ongoing

monitoring of BP with GP.
BP: 150 / 100 or above Was referred to GP for clearance to N/A
perform the Functional assessment due
to high BP
BP: 150 / 100 or N/A Presented with elevated blood
above & cleared by pressure which was cleared by
GP medical
practitioner. Would benefit from
ongoing monitoring of BP with GP
Questionnaire Restriction comment if relevant to All issues should be noted in
(Medical History) safe performance of the role medical history section on
summary page.
Weight > 120kg Should not operate equipment or N/A
machinery with a safe maximum weight
rating less than (insert candidates
weight).
BMI > 24.9kg N/A Would benefit from weight loss
to improve BMI
Reduced range of Presented with reduced range of motion Presented with reduced range of
movement or pain on (joint/direction) which would limit motion
the performance of the role (joint/direction) which would not limit
movement the performance of the role
Upper Limb Testing Document positive finding if it is relevant Document positive findings but would
to safe performance of the role not impact the performance of the
role
Abdominal Strength: N/A Would benefit from improving
Average or Poor abdominal strength
Hamstring and Back N/A Would benefit from improving
Flexibility: Below hamstring flexibility
average or worse
Bilateral Integration: Poor N/A Would benefit from improving
or very poor result core stability
Slump Test Positive Restriction comment if combination with Recommendation comment to
reduced performance in postural monitor signs if no impact observed
in postural tolerance task or manual
tolerance or manual handling tasks or handling task or would not impact on
would impact the performance of the the performance of role
role
Cardiovascular Fitness Very Poor result: Avoid sustained Below Average to Poor Result:
heavy physical activity due to poor Would benefit from improving
cardio- vascular fitness cardiovascular fitness
Postural Tolerance: Pain Avoid sustained or repetitive (list N/A
observed during tasks or tasks and include time if
time not achieved necessary) activities due to (list
reason)
Manual Handling max Limit lifting (list manual handling Would benefit from manual
weight task) activities to (list max weight handling training (if relevant)
not achieved or pain achieved) due to (list reason)
observed during lifting
Audio: two or more Referred for further audio (NB do N/A
frequencies not comment on range or
>45dB frequency)
Spirometry (Any of GP to review abnormal lung N/A
these) FVC <80% function. Employer will follow up
FEV1 < 80% with candidate
FVC:FEV1% < 70%
Colour Vision Should not perform tasks which are N/A
Two or more incorrect safety critical to colour vision until further
answers practical testing is performed. Employer
will follow up with candidate.
Visual Acuity Requires further testing for visual acuity N/A
Near Either eye N12 or by GP or Optometrist. Employer will
> Distance Best Eye 6/9 follow up with candidate.
or > OR Worst Eye 6/18
or >