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Work Capacity Form

The Work Capacity Form is a template used in the Injury Management and Rehabilitation Process to assess a patient's ability to work. It includes sections for patient and employer details, physical and mental health functions, and recommendations for return-to-work options. The form also allows for comments on the patient's capacity or limitations and requires the doctor's details for validation.

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parasbains221
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3 views

Work Capacity Form

The Work Capacity Form is a template used in the Injury Management and Rehabilitation Process to assess a patient's ability to work. It includes sections for patient and employer details, physical and mental health functions, and recommendations for return-to-work options. The form also allows for comments on the patient's capacity or limitations and requires the doctor's details for validation.

Uploaded by

parasbains221
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Work Capacity Form

Template version number: 1.1 Template version date: 5/10/2022


Franchise version number: 0.0 Franchise version date: 00/00/2020

Relevant Process: Injury Management and Rehabilitation Process

Patient and employer details


Family name: Given name:
Claim number: Date of birth:
Employer name:

Capacity to work is affected by the following


Physical function Can Modifications Cannot Comments
Sitting
Standing/Walking
Kneeling/squatting
Carrying/holding lifting
Reaching above shoulder
Bending
Use of affected body part
Neck movement
Climbing steps, stairs, ladders
Driving
Mental health function Not affected Partially Fully Comments
Attention/concentration
Memory (short or long term)
Judgement (decision making)
Other functional considerations
I have prescribed medication that could impact on your ability to undertake some activities
Details

Comments: (e.g. details of capacity or limitations that will assist in identification of suitable duties)

I would like more information about options available for return to work

I recommend
A graduated increase in hours over (weeks from) hours a day to normal hours/_____hours a day
Non- consecutive working days for a period of (days or weeks)
Full clearance (employee can return to full duties)
Doctors details
Name: Provider number:
Address:
Email: Phone:
Signed: Date:

© M&S Warner 2020 Page: 1 of 1


Each Home Instead Senior Care franchise office is independently owned and operated

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