Functional Capacities #1
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TimestampName of Individual being evaluated:Person Completing Form:WalkingKneelingTwistingClimbingCrouchingStoopingBalancingCrawlingTravelOtherIf yes, please explain:EatingChild CareMedication ManagementHygieneHousekeepingMoney ManagementLaundryToiletingShoppingCookingDressingUsing the TelephoneGroomingIndependent LivingSelf-injurious behaviorRepeat HospitalizationOtherIf yes, please explain:DependabilityJudgementPlanning ActivitiesFollowing RoutineFrequent ChangesInitiating ActivitiesMaking DecisionsBeing PunctualBeing OrganizedOtherIf yes, please explain:MemoryAttention SpanComprehensionLearning SpeedQuantitative SkillsMotor CoordinationManual DexterityEye/hand coordinationManipulates ObjectsSpatial/time ManagementOtherIf other please explain:StaminaStrengthTemperature ChangeCold/HeatHazardsNoise/VibrationsFumes/DustWork SpeedHigh PlacesWet/Humid EnvironmentSittingReachingChemical SensitivityPsychological FactorsStressStandingAbsenteeismLiftingOther CooperationGetting along with othersControlling EmotionsIf yes, please explain and be specific concerning lbs.If other, please explainTact/diplomacyUnderstanding Social CuesAccepting SupervisionSocial WithdrawalOtherSpeakingReadingHearingIf other. please explain:WritingInterviewingOtherIf other, please explain:
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3/28/2012 14:34:21TestTestNoYesNoYesYesNoYesNoNoYesComment 1NoYesNoYesYesNoYesNoYesNoNoYesNoYesNoNoYesComment 2YesNoNoNoNoYesNoYesNoYesComment 3YesNoYesNoNoYesNoNoYesNoYesComment 4YesNoNoNoNoYesNoNoYesNoYesYesNoNoNoYesYesNoYesNoYesNoComment LBsComment 5NoYesNoYesYesNoYesNoComment 6NoYesYesComment 7
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4/1/2012 18:34:47Comment test 2TES commentNoNoNoNoNoNoNoNoNoYesMobility CommentNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesSelf Care CommentNoNoNoNoNoNoNoNoNoYesSelf Direction CommentNoNoNoNoNoNoNoNoNoNoYesWork Skills CommentNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesNoNoNoLBS. CommentWork Tolerance CommentNoNoNoNoYesNoNoNoInterpersonal CommentNoNoYesCommunication Comment
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4/16/2012 22:16:01MAx ScoreMax ScoreYesYesYesYesYesYesYesYesYesYesMax ScoreYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesMax ScoreYesYesYesYesYesYesYesYesYesYesYesMax ScoreYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesMax ScoreMax ScoreYesYesYesYesYesYesYesYesMax ScoreYesYesYesMax Score
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4/16/2012 22:30:51Student 1BroegNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoYesYesNoYesNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo
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4/16/2012 22:37:25Student 2BroegNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoYesYesNoYesYesNoNoNoYesNoNoNoNoNoYesNoNoYesYesNoNoNoYesNoYesYesYesNoNoNoNoNoNoNoNoNoNoYesNoNoNoYesNoYesNoNoNoYesNoNoNoNoNoNoYesNoYesNoYesNoYesYesNoYesYesNo
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4/30/2012 15:45:44Joshua FlemingTanya VallsNoNoNoNoNoNoNoNoYesNoYesYesYesYesYesYesYesNoYesYesNoNoNoYesNoNoNoYesYesYesYesYesYesYesYesYesNoNoYesYesYesYesYesYesYesYesYesNoNoNoNoNoYesYesNoYesYesNoNoNoNoYesYesNoNoNoNoYesYesYesYesYesYesNoYesYesYesNoBeing appropriate at timesYesYesNo
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7/15/2012 20:01:45/sara jakeNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoYesNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNo
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9/19/2012 9:59:11LeaStacey NoNoNoNoYesYesYesNoYesNoLea is physically able to do these things, but her willingness to do them is the reason for the above answers.NoYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoNoLea is very limited in her ability to care for herself, although with direction/prompting she can perform some tasks.YesYesYesNoYesNoNoNoNoNoLea is very routine oriented and does not handle change well.YesYesYesYesYesNoNoNoNoYesNoYesYesYesYesYesYesYesYesYesNoNoNoNoNoYesNoNoYesNoYesNoYesLea has poor muscle tone and appears "fragile". YesYesNoNoNoYesYesNoYesYesNo
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9/19/2012 16:40:45HIHeffelfingerNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoYesNoNoYesNoNoNoYesYesNoNoNoYesYesYesNoNoYesYesNoYesNoYesYesYesYesYesNoNoNoNoNoNoYesNoNoNoNoNoNoYesNoNoNoNoNoNoYesNoYesNoNoNoNoNoNoNoNoNoNoNoYesNoYesYesNo
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12/21/2012 10:54:15Joe SchmoTYesYesYesYesYesNoNoYesNoNoYesNoNoYesNoYesYesNoYesYesNoNoYesYesNoNoNoYesNoYesNoNoYesYesNoNoNoNoYesNoYesYesYesNoNoYesNoNoYesNoYesNoYesYesYesNoYesNoNoYesNoYesNoNoYesYesNoYesNoYesNoYesNoYesNoYesNoYesYesNoNo
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1/24/2013 11:13:47michael mcmillanmichael mcmillanNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoYesYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoYesNoNo
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2/4/2013 7:10:20C JonesC GrangerNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesNoYesNoNoNoNoYesNoNoNoNoNoNoYesYesYesYesYesYesNoYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesYesYesNoNoNoYesNoYesYesNo
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2/7/2013 10:04:00WFMomNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesYesYesYesYesYesNoNoYesNoNoNoNoYesNoYesYesNoHigh anxiety, no cognitive weakness, high intelligenceNoNoNoNoNoYesYesYesYesNoNoNoYesNoYesNoNoNoNoNoNoYesIs only age 18 so lifting over 50 lbs not appropriate YesYesNoYesNoNoNoNoHigh anxiety means that he may not notice the social cuesNoYesNoHigh anxiety means he is usually nervous when the attention is on him, such as in interviews or interacting with people he doesn't know
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5/14/2013 9:24:28KCKJCYesYesNoYesYesYesYesNoYesNoNoYesNoYesYesYesNoNoNoYesNoYesYesYesNoNoNoYesYesYesNoYesYesYesYesYesNoYesYesNoYesYesYesNoNoYesYesNoNoYesNoNoNoNoYesNoYesYesNoNoYesYesYesYesNoYesNoNoNoYesNoYesYesYesNoNoYesNoYesYesNo
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5/1/2014 10:17:28Caleb CanadyChris McCainNoYesYesNoYesYesYesYesNoNoNoYesYesYesYesYesYesNoYesYesYesYesYesYesNoNoNoYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoYesNoYesYesYesGrasphing objects is difficult for Caleb.YesYesYesYesNoYesYesNoYesYesNo
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11/22/2014 14:46:54rrryyyYesYesYesNoYesNoYesYesNoNoYesNoYesYesYesYesNoYesYesYesYesYesYesYesYesYesYes;kuhYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYessdYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYeswdefwasdYesYesYesYesYesNoYesNoasdfYesYesYesadf
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12/9/2014 10:26:02TylerTylerNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoYesNoNoYesNoNoYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoYesNoYesNoNo
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12/17/2014 11:09:31PatPatNoNoNoNoNoNoYesNoNoNoNoNoNoNoYesYesNoNoYesNoNoNoNoYesNoNoNoNoYesNoNoYesYesYesNoYesNoNoYesYesYesYesNoNoNoNoYesNoNoNoNoNoNoNoNoYesYesNoNoNoYesNoYesNoNoNoNoNoNoNoNoYesNoNoNoNoYesNoNoYesNo
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1/20/2015 11:04:49jimsallyYesYesYesYesYesYesYesYesNoNoYesNoYesNoNoNoYesYesYesNoYesYesNoNoNoNoNoNoNoNoYesNoYesYesYesNoNoNoNoYesYesNoNoNoNoNoNoNoYesNoNoNoNoNoNoYesNoNoNoNoNoYesYesNoNoNoNoNoNoNoNoYesNoNoNoNoYesNoYesYesNo
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1/22/2015 11:34:43Evan KressEddie R. PearcyYesYesYesYesYesYesYesYesNoNoNoNoYesYesYesYesYesYesYesYesYesYesYesYesYesNoNoYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoYesNoYesYesYesYesNoYesYesNoYesYesNoYesYesNo
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2/5/2015 10:33:23DGBroegNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoNoYesNoYesNoNoNoYesNoYesNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo
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2/25/2015 21:34:17Taffy ValleyK. GarretsonYesYesNoYesYesNoNoNoNoYesknee injuryNoNoNoNoYesNoYesNoNoNoNoNoNoNoNoNoNoYesYesNoYesNoYesNoYesYesNoNoYesNoNoNoNoNoNoNoYesNoNoNoNoNoNoYesYesYesYesNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoNoNoNoNo
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3/26/2015 10:53:32StephenMrs. MillerYesYesNoYesYesYesYesNoYesNoYesNoNoYesNoYesYesYesYesYesYesYesYesYesNoNoNoNoYesYesNoNoYesYesNoYesNoYesYesYesYesYesYesNoNoNoYesNoYesYesNoNoYesNoNoYesYesNoNoNoNoYesYesYesNoYesNoYesYesYesYesYesYesNoNoYesYesNoYesYesNo
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3/29/2015 9:07:11Betty WillisBJF WillisYesYesYesYesYesYesNoYesYesNoYesNoNoNoNoNoNoYesNoNoYesNoNoNoNoNoNoNoNoNoYesYesNoNoNoNoNoNoNoNoNoNoYesYesYesYesYesNoNoYesYesYesNoYesNoNoNoNoYesYesNoYesYesNoNoNoNoYesYesNoNoNoNoYesNoYesNoYesNoNoNo
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5/7/2015 21:54:13Christina sue Hinger-EickeConnie EickeYesYesYesYesYesYesYesYesYesYesYes has quad c/pYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoYesChristina total depend on other for 99 0/0 of her daily livingYesYesYesYesYesYesYesYesYesYeschristina cognitive skill are 18 to 24 months some of at the 24 month she is still working on mastering.YesYesYesYesYesYesYesYesYesYesYesChristina has multiple disabilities physical cognitive and iq testing of 42YesYesYesYesYesYesYesYesYesYesNoYesYesNoNoYesNoYesNoNoNoYesChristina can't lift do to her quadriplegic cerebral palsyYesYesYesYesYesYesYesNoChristina is very limited language speak very few words YesYesYesChristina is very limited language speak very few words
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6/11/2015 12:39:57John DoeDustin HammersNoYesNoYesYesYesNoYesYesNoNoYesYesNoYesYesNoNoNoYesNoNoYesYesNoNoNoYesNoYesNoYesYesYesNoYesNoYesNoYesYesYesNoYesYesNoYesNoNoYesNoNoNoYesYesYesNoYesNoYesYesYesYesYesNoNoNoNoNoYesYesYesNoYesNoNoYesNoYesYesNo
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11/23/2015 19:58:55Keziah JonesKaren KishNoNoNoNoNoNoYesNoNoNoNoYesNoYesNoYesYesNoYesYesNoNoYesYesNoNoNoNoYesYesNoNoYesNoNoNoNoNoNoYesYesYesYesYesYesYesYesNoNoNoNoNoYesNoNoYesYesNoNoNoNoYesNoNoNoNoNoNoNoNoNoYesNoNoNoNoYesNoYesNoNo
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1/25/2016 12:34:30JohnLizNoYesNoYesNoNoNoNoNoNoNoYesYesNoYesYesYesYesYesYesNoNoNoYesNoNoNoYesNoNoYesNoNoYesYesYesNoNoYesNoNoNoNoNoNoYesNoNoNoYesNoNoYesYesNoYesYesYesNoNoYesNoNoNoNoNoNoYesYesNoYesYesYesYesNoYesNoYesYesYesNo
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3/28/2016 18:49:43Ivy GarmonIvy GarmonYesNoNoNoNoNoYesNoYesNogoYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesYesgoYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesYesYesYesYes
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4/19/2016 12:39:59Caleb BennettTiffany EnglishNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoYesYesNoYesYesNoNoNoYesNoNoNoYesYesNoNoNoNoNoNoYesNoYesYesYesYesYesYesYesYesNoYesNoNoNoNoNoYesNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesYesNoYesNoYesYesNoYesYesNo
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5/10/2016 17:36:17djYesYesYesYesYesYesYesYesYesYesIDKYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoNoNoYesYesYesYesYesYesYesYesYesNoYesYesYesNoYesYesYesYesYesYesNoYesYesYesYesYesYesYesYesYesYesYesYesNoNoNoYesNoYesNoYesYesYesYesYesYesNoNoYesYesYesYesYesNo
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7/22/2016 16:52:33JenniferGeeNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoYesYesNoYesYesNoNoNoYesNoNoNoYesNoYesNoNoYesYesYesYesNoYesYesYesYesNoNoNoNoNoYesNoNoNoNoNoNoYesNoYesNoNoNoNoNoYesYesNoNoNoNoYesYesYesYesYesNoYesNoNoNoYesYesYesNo
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8/17/2016 11:31:22Cody GistCassey TrustyYesYesYesYesYesYesYesYesNoNoYesNoNoNoNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoYesNoNoNoNoYesNoYesNoNoNoNoYesYesYesYesNoNoYesYesYesYesNoNoNoNoNoNoYesYesNoYesNoYesNoNoNoYesYesYesNoNoYesYesNoNoNoYesYesNoNo
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4/6/2017 14:11:49Javier Rich Erika BurdickNoNoYesNoNoNoNoYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoYesYesNoNoYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesNoYesYesYesYesYesYesNoNoYesYesNoYesYesNo
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