Transcription of Functional Capacity Evaluation - WorkWell
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Functional Capacity Evaluation - WorkWell
(866) 997 9675 SAMPLE REPORT RETURN TO WORK Client Name: Frank T. Date of FCE: 1/05/2011 Therapist: Laurie T. Referrer: Dr. Smith Facility WorkWell Prevention & Care 11 East Superior Street, Suite 410 Duluth, MN 55802 866 997 9675 Functional Capacity Evaluation (866) 997 9675 R DR Emt Csare Pa Sd Qatt Ac Le Summary RepName: Frank Test Date: 1/0 DOB: 8/20/19 Date of InjuryGender: M Address: CanCity: Duluth State: MN Zip Code: 558 Physician: DrEmployer: CoPrimary Diagnmpingement Secondary DiaReason for TeDescription oRTW. Effort and Coomaximum effotest items. Consistency ostrength limitabilities as meright shoulderexamination aPain Report: activities. HeSafety: Clientdid require inQuality of Moasymmetrical to crown liftintest , anLimitations: Welevated work port T.
WorkWell FCE History Name: Frank T. Test Date: 1/5/2011 DOB: 8/20/1956 Date of Injury: 8‐15‐2010 Gender: M Address: Canal Park Drive City: Duluth State: MN Zip Code: 55806 Physician: Dr. Smith Employer: Company A
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