Patient Name: _______________________________________

Social Security #: ____________________________________

Date of Birth: ________________________________________

Please complete the following evaluation of your patient's ability to perform work activities. Indicate the level of work your patient can perform despite his or her limitations. This assessment must be based on objective clinical observations and/or laboratory findings. The levels of work activity at any levels of work activity used on this form are defined on page three.

To be able to perform the work activity at any level you patient must be able to perform substantially all of the requirements for work at that level for a sustained 8 hour day, five days a week. For example, to perform sedentary work, an individual must be able to sit 6 to 8 hours without constant breaks to stand and stretch.

Please describe the patient's abilities with respect to the following:

A.	If lifting/carrying affected by impairment? Yes_____ No_____
	If yes, how many pounds can the individual lift and/or carry? ______
	Maximum occasionally (from very little up to 1/3 of an 8-hour day? _____
	Maximum frequently (from 1/3 to 2/3 of an 8-hour day)? ______
	What are the medical findings that support this assessment?
	__________________________________________________________________
B.	Are standing/walking affected by impairment? Yes_____ No_____
	If yes, how many hours in an 8-hour workday cam the individual stand and/or walk: total? ______ without interruption? ______
	What are the medical findings that support this assessment?
	__________________________________________________________________
C.	Is sitting affected by impairment? Yes_____ No_____
	If yes, how many hours in an 8-hour workday cam the individual sit: total? ______ without interruption? ______
	What are the medical findings that support this assessment?
	__________________________________________________________________
D.	How often can the individual perform the following postural activities?

	Frequently	Occasionally	Never
(Frequently=1/3 to 2/3 of an 8-hour workday; Occasionally= very little to 1/3 of an 8-hour workday)
Climb	________	________	________
Balance	________	________	________
Stoop	________	________	________
Crouch	________	________	________
Kneel	________	________	________
Crawl	________	________	________
Operate foot controls	________	________	________
Reach above right shoulder level	________	________	________
Reach above left shoulder level	________	________	________
Gross manipulations(Simple Grasping)	________	________	________
Fine manipulations(wire, small tools)	________	________	________

	What are the medical findings that support this assessment?
	__________________________________________________________________
E.	Are the following physical functions affected by the impairment?

	Yes	No
Reaching	_______	_______
Handling	_______	_______
Feeling	_______	_______
Puching/Pulling	_______	_______
Seeing	_______	_______
Hearing	_______	_______
Speaking	_______	_______

	What are the medical findings that support this assessment?
	__________________________________________________________________
F.	Are there environmental restrictions caused by the impairment?

	Yes	No
Heights	_______	_______
Moving machinery	_______	_______
Temperature extremes	_______	_______
Chemicals	_______	_______
Dust	_______	_______
Noise	_______	_______
Fumes	_______	_______
Humidity	_______	_______
Vibrations	_______	_______
Other	_______	_______

	How do the checked restrictions affect the individual's activities
	__________________________________________________________________
	What are the medical findings that support this assessment?
	__________________________________________________________________
G.	State any other work related activities which are affected by the impairment, and indicate how the activities are affected. What are the medical findings that support this assessment?
	__________________________________________________________________
	__________________________________________________________________

Date Report Completed:	______________________________
Signature of Physician:	______________________________
Physician Name:	______________________________
Address:	______________________________
Telephone:	______________________________
Specialty:	______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357

SEDENTARY WORK:

Sedentary work entails lifting 10 pounds maximum and occasionally lifting or carrying such articles as dockets (e.g. files), ledgers and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required and other sedentary criteria are met. An individual cannot perform sedentary work if (s)he is unable to sit hours without standing.

LIGHT WORK:

Light work entails lifting 20 pounds maximum with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree, or when it involves sitting most of the time with a degree of pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of substantially all of the forgoing activities. The functional capacity to perform light work includes the functional capacity to perform sedentary work.

MEDIUM WORK:

Medium work entails lifting 50 pounds maximum with frequent lifting or carrying of objects weighing up to 50 pounds. The functional capacity to perform medium work includes the capacity to perform work at all of the lesser functional levels.

HEAVY WORK:

Heavy work entails lifting 100 pounds maximum with frequent lifting or carrying of objects weighing up to 50 pounds. The functional capacity to perform heavy work includes the capacity to perform work at all of the lesser functional levels.

VERY HEAVY WORK:

Very heavy work entails lifting objects in excess of 100 pounds with frequent lifting or carrying of objects weighing up to 50 pounds or more. The functional capacity to perform very heavy work includes the capacity to perform work at all of the lesser functional levels.