| 46613-6 | Remembers locations and worklike procedures (qualitative) |
| 46614-4 | Understands and remembers very short and simple instructions (qualitative) |
| 46615-1 | Understands and remembers detailed instructions (qualitative) |
| 46616-9 | Carries out very short and simple instructions (qualitative) |
| 46617-7 | Carries out detailed instructions (qualitative) |
| 46618-5 | Maintains attention and concentration for extended periods (qualitative) |
| 46619-3 | Performs activities within a schedule, maintains regular attendance, is punctual within customary tolerances (qualitative) |
| 46620-1 | Sustains an ordinary routine without special supervision (qualitative) |
| 46621-9 | Works in coordination with or proximity to others without being distracted (qualitative, them) |
| 46622-7 | Makes simple work-related decisions (qualitative) |
| 46623-5 | Completes normal workday and week WO interruptions from psych symptoms and performs at consistent pace WO unreasonable number and length of rests (qualitative) |
| 46624-3 | Interacts appropriately with the general public (qualitative) |
| 46625-0 | Asks simple questions or request assistance (qualitative) |
| 46626-8 | Accepts instructions and respond appropriately to criticism from supervisors (qualitative) |
| 46627-6 | Gets along with coworkers or peers WO distracting them or exhibiting behavioral extremes (qualitative) |
| 46628-4 | Maintains socially appropriate behavior and adheres to basic standards of neatness and cleanliness (qualitative) |
| 46629-2 | Responds appropriately to changes in the work setting (qualitative) |
| 46630-0 | Aware of normal hazards and take appropriate precautions (qualitative) |
| 46631-8 | Travels in unfamiliar places or use public transportation (qualitative) |
| 46632-6 | Sets realistic goals or make plans independently of others (qualitative) |
| 46633-4 | Remarks |
| 46634-2 | Functional capacity assessment |
| 46635-9 | Categories |
| 46636-7 | Date form completed |
| 46637-5 | Residual physical functional capacity (RFC) assessment form |
| 46638-3 | IP CDB claim numberholder |
| 46639-1 | Primary diagnosis |
| 46640-9 | Secondary diagnosis |
| 46641-7 | Other alleged impairments |
| 46642-5 | Limitations section Set |
| 46643-3 | Exertional limitations Set |
| 46644-1 | No exertional limitations (qualitative) |
| 46645-8 | Occasionally lift/carry (qualitative) |
| 46646-6 | Frequently lift/carry (qualitative) |
| 46647-4 | Stand/walk (qualitative) |
| 46648-2 | Sit (qualitative) |
| 46649-0 | Push/pull (qualitative) |
| 46650-8 | Exertional limitations |
| 46651-6 | Postural limitations Set |
| 46652-4 | No postural limitations (qualitative) |
| 46653-2 | Climbing (qualitative) |
| 46654-0 | Balancing (qualitative) |
| 46655-7 | Stooping (qualitative) |
| 46656-5 | Kneeling (qualitative) |
| 46657-3 | Crouching (qualitative) |
| 46658-1 | Crawling (qualitative) |
| 46659-9 | Postural limitations |
| 46660-7 | Manipulative limitations Set |
| 46661-5 | No manipulative limitations (qualitative) |
| 46662-3 | Reaching in all directions (qualitative) |
| 46663-1 | Handling (qualitative) |
| 46664-9 | Fingering (qualitative) |
| 46665-6 | Feeling (qualitative) |
| 46666-4 | Manipulative limitations |
| 46667-2 | Visual limitations Set |
| 46668-0 | No visual limitations (qualitative) |
| 46669-8 | Near acuity (qualitative) |
| 46670-6 | Far acuity (qualitative) |
| 46671-4 | Depth perception (qualitative) |
| 46672-2 | Accommodation (qualitative) |
| 46673-0 | Color vision (qualitative) |
| 46674-8 | Field of vision (qualitative) |
| 46675-5 | Visual limitations |
| 46676-3 | Communicative limitation Set |
| 46677-1 | No communicative limitations (qualitative) |
| 46678-9 | Hearing (qualitative) |
| 46679-7 | Speaking (qualitative) |
| 46680-5 | Communicative limitation |
| 46681-3 | Environmental limitations Set |
| 46682-1 | Extreme cold (qualitative) |
| 46683-9 | Extreme heat (qualitative) |
| 46684-7 | Wetness (qualitative) |
| 46685-4 | Humidity (qualitative) |
| 46686-2 | Noise (qualitative) |
| 46687-0 | Vibrations (qualitative) |
| 46688-8 | Fumes, odors, dusts, gases, poor ventilation, etc (qualitative) |
| 46689-6 | Hazards (qualitative) |
| 46690-4 | Environmental limitations |
| 46691-2 | Symptoms |
| 46692-0 | Treatment or examining source statements Set |
| 46693-8 | Treating or examining source statement regarding claimant's physical capacities in file (qualitative) |
| 46694-6 | Treating or examining source conclusions about the claimant's limitations or restrictions which are significantly different from your file |
| 46695-3 | Why conclusions are not supported (the evidence in file) |
| 46696-1 | Additional comments |
| 46697-9 | Date |