Functional Capacity Evaluation Form – Fill Out and Use This PDF

Updated: Nov 9, 2026

The Functional Capacity Evaluation (FCE) form is a comprehensive document designed to be filled out by a treating physician. It assesses a patient's capacity to perform work-related tasks, categorizing the type of work they can handle—from sedentary to very heavy work—based on their ability to lift, carry, sit, stand, and perform various other physical activities. To understand your or your patient's work capabilities better and to provide accurate information to employers or insurance entities, click the button below to fill out the form.

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How to Fill Out Estimated Functional Capacity Evaluation

Estimated Functional Capacity Evaluation at a glance

What it is: This is the estimated functional capacity evaluation.

Who signs: It is to be completed by the treating physician.

A filled-in Estimated Functional Capacity Evaluation example: a physician estimates one patient

Estimated Functional Capacity Evaluation example filled out, example: a physician estimates one patient — Dr. Alex Sample fills out this evaluation for patient Jordan Sample. Jordan is estimated to occasionally lift up to 10# and to continuously bend. The picture shows page 1, and all its values are invented.

How to fill out Estimated Functional Capacity Evaluation, box by box

Patient, lift, carry, tasks and workday hours

Fill in Patient.

For 1. LIFT, estimate this person to be able to lift up to 10#, 11 - 24#, 25 - 34#, 35 - 50#, 51 - 74# and 75 - 100#, as Never, Occasionally (1-33%), Frequently (34-66%) or Continuously (67-100%).

For 2. CARRY, estimate this person to be able to carry up to 10#, 11 - 24#, 25 - 34#, 35 - 50#, 51 - 74# and 75 - 100#, as Never, Occasionally (1-33%), Frequently (34-66%) or Continuously (67-100%).

For 3., mark Never, Occasionally (1-33%), Frequently (34-66%) or Continuously (67-100%) for each of Push/Pull - Seated, Push/Pull - Standing, Bend, Squat, Crawl, Climb and "Reach above shoulder level".

For 4., assuming an 8-hour workday with two 15-minute breaks and an hour meal break, circle the number of hours, 1 to 8, for each activity (Sit, Stand, Walk and Alternately Sit/Stand), Continuously or With Rests. Total does not have to equal 8 hours.

Hands, feet, restrictions, job, comments, physician and signature

For 5. Can person use hands for repetitive actions such as: Simple Grasping, Firm Grasping and Fine Manipulating, mark Yes or No for Right and for Left, and enter the Estimated Grip Strength for Right and Left.

For 6. Can person use feet for repetitive movements as in operating foot controls?, mark Yes or No for Right (Alone), Left (Alone) and Both (Simultaneously).

For 7. Any restrictions of activities involved?, mark None, Mild, Moderate or Total for Unprotected Heights, Being around moving machinery, Exposure to marked changes in temperature and humidity, Driving automotive equipment and Exposure to dust; fumes; gases.

For 8. Can person continue in current job?, mark Yes or No. If not, mark Yes or No for can person return to other work according to restrictions defined in 7. Any restrictions of activities involved?

Mark Yes or No for Can the person work full-time. If not, mark Yes or No for can the person work part-time. If the person can work part-time but not full-time, estimate the schedule, in hours per day and days per week. Enter the Disability rating (if applicable) in %.

Write the 9. COMMENTS.

Fill in Physician Name, Address, City, State, Zip, Telephone, Field of Specialty and License No.

SIGN: enter the Signature and the Date.

More rules for Estimated Functional Capacity Evaluation

SEDENTARY WORK is lift 10# maximum and occasionally carry small objects; LIGHT WORK is lift 20# maximum; frequently lift/carry up to 10#; MEDIUM WORK is lift 50# maximum; frequently lift/carry up to 25#; HEAVY WORK is lift 100# maximum; frequently lift/carry up to 50#; VERY HEAVY WORK is lift in excess of 100#; frequently lift/carry 50#.

Sources

[1] Estimated Functional Capacity Evaluation (the served file; no issuer file found) (the Official source link on this page).

Functional Capacity Evaluation Form PDF Details

In the landscape of employment and health, the Functional Capacity Evaluation (FCE) form serves as a critical bridge, providing a structured framework through which treating physicians can articulate the physical capacities and limitations of their patients in the context of work. At its core, the form categorizes work into different levels based on the physical demand required—ranging from sedentary to very heavy work—allowing for a nuanced assessment of an individual's ability to lift, carry, and engage in various physical tasks. Additionally, it offers a detailed look into a person's capacity to perform day-to-day activities within a standard workday, including sitting, standing, walking, and the ability to alternate between these positions, factoring in necessary breaks. The evaluation delves deeper by examining the capability for repetitive hand and foot actions, essential for numerous job functions. Any restrictions on activities due to environmental conditions or specific job hazards are also meticulously recorded, ensuring a comprehensive view of the patient's work-related capabilities and restrictions. Moreover, it opens up discussions about the feasibility of continuing in current employment or the necessity of exploring alternative work options, taking into account partial or potential disability considerations. Signed off by the treating physician, this document not only influences immediate employment options but also has long-reaching implications for patient care, occupational health strategies, and the broader discourse on work and disability.

Question	Answer
Form Name	Functional Capacity Evaluation Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	functional capacity evaluation form, functional eval test, estimated functional capacity evaluation, estimated evaluation