Work Capacity Evaluation for Disability Insurance
Patient Information
Name
Date of Birth
Patient ID/Number
Diagnosis
Primary Diagnosis
Secondary Diagnosis(es)
Treatment Plan
Describe current treatment plan
Work Capacity Assessment
Patient is able to (select all that apply):
Work full time
Work part time
Work with restrictions
Unable to work
Functional Limitations
List and describe any functional limitations
Expected Duration of Limitations
Weeks
Months
Additional Comments
Comments
Provider Information
Provider Name
Specialty
Phone Number
Date
Signature