It appears you have not yet Signed Up with our community. To Sign Up for free, please click here....



Pain Management Message Board

  • RFC Forms

  • Post New Thread   Closed Thread
    Thread Tools Search this Thread
    Old 08-18-2004, 08:20 PM   #1
    rhoff
    Newbie
     
    rhoff's Avatar
     
    Join Date: Mar 2004
    Posts: 5
    rhoff HB User
    Question RFC Forms

    Does anybody out there know where on the net
    I can print out a free copy of an RFC (Residual Functional Capacity)
    form ? Having a hard time.

    Thanks
    Bob

     
    Sponsors Lightbulb
       
    Old 08-21-2004, 11:10 AM   #2
    lindao1
    Veteran
    (female)
     
    Join Date: Jul 2003
    Location: Jacksonville, Florida USA
    Posts: 440
    lindao1 HB User
    Re: RFC Forms

    Hi Bob,

    Sorry I just saw your post. I can't believe it but about a week ago I printed off a complete RFC form - an apparent "official" form. But the trash went out and so did it.

    I initially found it by doing a search for "RFC". I had to keep going page after page and then finally found it. It takes some time searching but you will be able to find the form and questions. Most questions were related to mobility or lack there of. Like standing, bending, lifting, pulling, sitting, daily activities, etc.

    Just look hard and you will find it! Hope this helps! Linda

     
    Old 05-04-2005, 12:50 PM   #3
    ymmij
    Newbie
    (male)
     
    ymmij's Avatar
     
    Join Date: Apr 2005
    Posts: 3
    ymmij HB User
    Re: RFC Forms

    Hi BOB,
    You can get a copy of an RFC form for the Social Security website at this link [url]http://policy.ssa.gov/poms.NSF/lnx/0424510055[/url]. It also can be downloaded in a PDF version. Just copy and paste the url.
    Jim

    Last edited by ymmij; 05-04-2005 at 12:51 PM.

     
    Old 05-05-2005, 12:35 PM   #4
    ymmij
    Newbie
    (male)
     
    ymmij's Avatar
     
    Join Date: Apr 2005
    Posts: 3
    ymmij HB User
    Lightbulb Copy Of A Rfc Form

    RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE


    Name of Claimant: _____________________________ SSN: _______________________


    DEAR DOCTOR: PLEASE COMPLETE THE FOLLOWING ITEMS BASED ON YOUR CLINICAL

    EVALUATION OF THE CLAIMANT AND OTHER TESTING RESULTS. ANY ITEMS THAT YOU

    DO NOT BELIEVE YOU CAN ANSWER SHOULD BE MARKED N/A (NOT ANSWERABLE).


    NOTE: IN TERMS OF AN 8 HOUR WORKDAY: "OCCASIONALLY" EQUALS 0% TO 33% (1-2

    HRS); "FREQUENTLY" 34% TO 66% (3-5 HRS); AND "CONTINUOUSLY" 67% TO 100% (6 TO 8

    HRS).

    ________________________________________ ________________________________________ ___

    I. In an 8-hr. workday, claimant can: (Circle full capacity for each activity)

    A. Sit - No. hrs. - 0, 1, 2, 3, 4, 5, 6, 7, 8.

    B. Stand - No. hrs. - 0, 1, 2, 3, 4, 5, 6, 7, 8.

    C. Walk - No. hrs. - 0, 1, 2, 3, 4, 5, 6, 7, 8.

    D. Work - No. hrs. - 0, 1, 2, 3, 4, 5, 6, 7, 8.

    (Sitting, standing or walking)

    ________________________________________ ________________________________________ ____

    II. Claimant can lift:

    Never Occasionally Frequently Continuously

    A. Up to 10 lbs. (___) (___) (___) (___)

    B. 11 - 20 lbs. (___) (___) (___) (___)

    C. 21 - 50 lbs. (___) (___) (___) (___)

    D. 51 - 100 lbs (___) (___) (___) (___)

    Limitations due to:

    ________________________________________ ________________________________________ ____

    III. Claimant can carry:

    Never Occasionally Frequently Continuously

    A. Up to 10 lbs. (___) (___) (___) (___)

    B. 11 - 20 lbs. (___) (___) (___) (___)

    C. 21 - 50 lbs. (___) (___) (___) (___)

    D. 51 - 100 lbs (___) (___) (___) (___)

    Limitations due to:

    ________________________________________ ________________________________________ ____

    IV. Claimant can use hands for repetitive action such as:

    Simple Grasping Pushing & Pulling Fine Manipulation

    A. Right (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No

    B. Left (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No

    Limitation due to :

    ________________________________________ ________________________________________ ____

    V. Is there evidence of any disorder that would limit in any way repetitive hand action

    involving:

    Simple Grasping Pushing & Pulling Fine Manipulation

    A. Right (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No

    B. Left (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No

    Limitation due to :

    **************************************** *************************************

    Page 2

    Name: _____________________________________ SSN _______________________________


    VI. Claimant can use feet for repetitive movements as in operating foot controls:

    Right Left Both

    (__) Yes (___) No (__) Yes (___) No (__) Yes (___) No

    Limitation due to:

    ________________________________________ ________________________________________ ____

    VII. Claimant is able to:

    Never Occasionally Frequently Continuously

    A. Bend (___) (___) (___) (___)

    B. Squat (___) (___) (___) (___)

    C. Crawl (___) (___) (___) (___)

    D. Climb (___) (___) (___) (___)

    E. Reach above (___) (___) (___) (___)

    F. Stoop (___) (___) (___) (___)

    G. Crouch (___) (___) (___) (___)

    H. Kneel (___) (___) (___) (___)

    Limitations due to:

    ________________________________________ ________________________________________ ____

    VIII. Claimant can tolerate:

    Not at all Occasionally Frequently Continuously

    A. Exposure to unpro-

    tected heights (___) (___) (___) (___)

    B. Being around

    moving machinery (___) (___) (___) (___)

    C. Exposure to marked

    temperature changes (___) (___) (___) (___)

    D. Driving automotive

    equipment (___) (___) (___) (___)

    E. Exposure to dust,

    fumes & gases (___) (___) (___) (___)

    F. Exposure to noise (___) (___) (___) (___)

    G. Other __________ (___) (___) (___) (___)

    Limitations due to:

    ________________________________________ ________________________________________ ____

    IX. Objective signs of pain:

    (___) Redness (___) Joint deformity (___) Spinal deformity (___) X-ray (___)

    Muscle spasm (___) Other (specify) ________________________________________ _______

    ________________________________________ ________________________________________ ____

    X. Pain is:

    (___) Mild (would constitute an awareness but causing no handicap in the performance of the

    particular activity, would be considered as nonratable permanent disability).

    (___) Slight (could be tolerated but would cause some handicap in the performance of the

    activity precipitating pain).

    (___) Moderate (could be tolerated but would cause marked handicap in the performance of the

    activity precipitating pain).

    (___) Severe (would preclude the activity precipitating the pain).

    **************************************** *************************************

    Page 3

    Name: ____________________________________ SSN _______________________________


    Remarks:





    ________________________________________ ________________________________________ ____



    ______________________________ _____________________________________

    (Date) (Signature of Physician)




     
    Closed Thread

    Related Topics
    Thread Thread Starter Board Replies Last Post
    short term disability forms & irate Dr. Aprilrain Disabilities 6 06-03-2008 04:41 AM
    Beating Rosacea, Vascular, Ocular & Acne Forms grammaed Rosacea 0 04-26-2004 09:36 AM
    Metamucil forms latayy26 Bowel Disorders 1 02-04-2004 09:28 PM




    Thread Tools Search this Thread
    Search this Thread:

    Advanced Search

    Posting Rules
    You may not post new threads
    You may not post replies
    You may not post attachments
    You may not edit your posts

    BB code is On
    Smilies are On
    [IMG] code is Off
    HTML code is Off
    Trackbacks are Off
    Pingbacks are Off
    Refbacks are Off




    Sign Up Today!

    Ask our community of thousands of members your health questions, and learn from others experiences. Join the conversation!

    I want my free account

    All times are GMT -7. The time now is 12:35 AM.





    © 2020 MH Sub I, LLC dba Internet Brands. All rights reserved.
    Do not copy or redistribute in any form!