Functional Assessment Systems, Inc.
Functional Capacity Evaluation
Sample Report

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Client’s perceptions regarding his pain is illustrated in the Pain Drawing Chart presented below.

 

Figure 2 – Pain Drawing Chart

Client’s description of his symptoms (reproduced from chart completed by examinee at the conclusion of testing). Pain level prior to testing was 4/10, Best pain level has been in the past month is 2/10, Worst is 8/10. Pain level at the conclusion of testing was 6/10.

 

 

FFigure 3 –Perceived Exertion

Client’s perceived exertion during this evaluation.  0 indicates no exertion, and 10 is the highest level of exertion one could imagine.  The scale is non-linear with a value of 2 for light, 3 for moderate, 5 for strong and 7 for very strong.  If heart rate values were measured during a test, the peak heart rate will appear over the exertion level bar as a shaded circle using the scale shown to the right.

Perceived Exertion Values Listed by Test Number – Test Names and Start Time of Test Appear Below

1: CAFT Step Test................ (12/17/2001 11:00)

10: Position 5....................... (12/17/2001 11:23)

19: PULL IN........................ (12/17/2001 11:42)

2: Lumbar Flexion/Extension... (12/17/2001 11:09)

11: FLOOR LIFT.................. (12/17/2001 11:27)

20: Floor to Knuckle Frequent. (12/17/2001 11:45)

3: Lumbar Lateral Flexion....... (12/17/2001 11:10)

12: H FLOOR LIFT.............. (12/17/2001 11:29)

21: Carry.............................. (12/17/2001 11:56)

4: Straight Leg Raise Right..... (12/17/2001 11:15)

13: TORSO LIFT................. (12/17/2001 11:31)

22: Walk.............................. (12/17/2001 11:58)

5: Straight Leg Raise Left........ (12/17/2001 11:16)

14: H TORSO LIFT.............. (12/17/2001 11:34)

23: Stoop............................. (12/17/2001 12:01)

6: Position 1......................... (12/17/2001 11:19)

15: ARM LIFT..................... (12/17/2001 11:35)

24: Crouch........................... (12/17/2001 12:03)

7: STANDARD.................... (12/17/2001 11:20)

16: HIGH NEAR LIFT........... (12/17/2001 11:37)

25: Kneel............................. (12/17/2001 12:09)

8: Position 3......................... (12/17/2001 11:21)

17: H HIGH NEAR LIFT....... (12/17/2001 11:39)

9: Position 4......................... (12/17/2001 11:22)

18: PUSH OUT.................... (12/17/2001 11:40)

 

 

 


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