PHYSICAL FUNCTIONAL EVALUATION
DSHS 13-021 (REV. 06/2020)
Page 1
Physical Functional Evaluation
1. Payment for a general or comprehensive physical evaluation is contingent upon receipt of available chart notes from
within the past six months, as well as supporting evidence including lab results, pathology reports, diagnostic
imaging reports, and range of motion studies. You must be enrolled in ProviderOne to claim reimbursements for
these services.
2. As you examine this patient, please evaluate all medical conditions that may limit their ability to work. You are not
limited to evaluating the presenting condition(s). You are not required to complete any special test of functional
capacity to render your professional medical opinion on this form.
Confidentiality: The information you provide is subject to Washington State Public Disclosure laws and may be
released to the client upon request. DSHS discloses no further information without the written consent of the
individual to whom it pertains or as otherwise permitted by state law.
A. Client Information
NAME
BIRTH DATE
CLIENT IDENTIFICATION NUMBER
B. Authorization to Release Information
I authorize to release the following information to the Department of
EXAMINING PROFESSIONAL’S NAME
Social and Health Services (DSHS). This release includes the contents of this evaluation as well as diagnostic testing or
treatment information concerning mental health, alcohol or drug use , sickle cell disease, and sexually transmitted
disease, including HIV/AIDS (Chapter 70.02 Revised Code of Washington (RCW) (42 Code of Federal Regulations
(CFR) Part 2).
This authorization is valid for one year or until (date).
I may revoke or withdraw this authorization in writing at any time.
I understand that the information provided to DSHS may be re-disclosed only with a valid authorization from me or if
required by law.
DATE
C. Subjective
Chief complaints and reported symptoms:
PHYSICAL FUNCTIONAL EVALUATION Page 2
DSHS 13-021 (REV. 06/2020)
Reported onset of primary impairment: (date).
Describe any treatment history including hospitalizations:
D. Objective
Attach chart notes detailing examination findings.
Describe any non-exertional limitations or workplace restrictions (such as chemical sensitivities or inability to work at
heights):
List all laboratory, imaging, range of motion, and other diagnostic test results (attach reports):
E. Assessment
1. List each diagnosis in Column 1 below, starting with the primary impairment.
2. In Column 3 below, estimate the severity of the diagnosis based on your professional medical opinion using the
following definitions:
RATING
SEVERITY
DEFINITION
1 None No interference with the ability to perform one or more basic work-related activities
2 Mild No significant interference with the ability to perform one or more basic work-related activities
3 Moderate Significant interference with the ability to perform one or more basic work-related activities
4 Marked Very significant interference with the ability to perform one or more basic work-related activities
5 Severe Inability to perform one or more basic work-related activities
Basic work activities include (a) sitting, (b) standing, (c) walking, (d) lifting, (e) carrying, (f) handling, (g) pushing,
(h) pulling, (i) reaching, (j) stooping, (k) crouching, (l) seeing, (m) hearing, and (n) communicating.
DIAGNOSIS
AFFECTED WORK ACTIVITY
(See (a) – (n) above)
SEVERITY
RATING
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DSHS 13-021 (REV. 06/2020)
In your professional medical opinion, what work level is the client capable of performing in a regular* predictable manner
despite their impairment?
Heavy work .......Able to lift 100 pounds maximum and frequently** lift or carry up to 50 pounds.
Medium work.....Able to lift 50 pounds maximum and frequently** lift and/or carry up to 25 pounds.
Light work .........Able to lift 20 pounds maximum and frequently** lift or carry up to 10 pounds, able to walk or stand
six out of eight hours per day, and able to sit and use pushing or pulling arm or leg movements
most of the day.
Sedentary work .Able to lift 10 pounds maximum and frequently** lift or carry lightweight articles. Able to walk or
stand only for brief periods.
Severely limited .Unable to meet the demands of sedentary work.
* Regular predictable manner means the person is capable of sustaining the work level over a normal workday and
workweek on an ongoing, appropriate, and independent basis.
** Frequently means the person is able to perform the function for 2.5 to 6 hours out of an 8 hour day. It is not
necessary that performance be continuous.
DURATION
How long do you estimate the current limitation on work activities will persist with available medical treatment?
MONTHS
SUBSTANCE ABUSE
Are the effects on basic work activities primarily the result of substance use disorder? Yes No
Please explain:
Would the effects on basic work activities persist following 60 days of sobriety? Yes No
If not, how would they change?
Is a chemical dependency assessment of substance use treatment recommended? Yes No
F. Plan
List any additional tests or consultations needed:
What treatment is recommended?
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DSHS 13-021 (REV. 06/2020)
RETURN THIS REPORT TO:
PRINT NAME OF EXAMINING PROFESSIONAL
EXAMINATION DATE
SPECIALTY AREA/ADVANCED TRAINING
TELEPHONE NUMBER
WORKER SIGNATURE DATE
STREET ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER
EXAMINING PROFESSIONAL’S SIGNATURE/TITLE
DATE
FAX NUMBER
REVIEWING AND ADOPTING PROFESSIONAL’S SIGNATURE
DATE