Functional Capacity Certificate Form 507

Functional Capacity Certificate Form 507
Fcc 507 rev 1 03 05 2008
Name: 1 of 2Functional Capacity CertifNOTE: TO BE COMPLETED BY SERVICE MEMBER:

PLEASE READ QUESTIONS CAREFULLY: Answer All Questions by placing an X in the appropriate block.This information constitutes an Official Statement.

Certain medical conditions and/or limitations may indicate need for further evaluation and/or additional information and/or change in Profile and/or referral to Medical Evaluation Board (MEB) and/or Military Occupational Specialty Medical Board (MMRB).Bracketed Numbers ([1], [2], [3]) may be reflected in your Physical Profile.
If YES, can you walk 4 miles in Combat Boots?
YES [2]

NO [3] Soldiers may be required to walk 12 miles with Field Gear (BDU, Helmet, LBE, Canteens, Protective Mask, Weapon, Without Rucksack).Do you have a Medical Condition that prevents you from doing so?

What is the Medical Condition?
YES [ ]

NO [1]
If YES, can you walk 4 miles with Field Gear?
YES [2]

NO [3]
If YES, can you walk

mile with Field Gear and Ruck Sack?
YES [2]

NO [3] Soldiers may be required to lift and carry 40 lbs.

(2 cases of canned soda) a distance of 100 feet.Do you have a Medical Condition that prevents you from doing so? What is the Medical Condition?
YES [ ]

NO [1]
If YES, can you lift and carry 35 lbs.(17 computer monitor) 100 feet?

YES [2]

NO [3]
If YES, can you remain on your feet for 1 hour?
YES [2]
NO [3] Please complete the following:
How far can you walk in Boots? ________with Field Gear? ________with Field Gear and Rucksack? ________
How much and how far can you lift and carry? ________lbs.________feet

How long can you remain on your feet? Hours:

________ or Minutes: ________

Do you have a Medical Condition that prevents you from carrying and firing individual assigned Weapon?

YES [3]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from moving with a Fighting Load (48 lbs) 2 miles?

(Includes: Helmet, Uniform, Boots, Load Bearing Equipment (LBE), Weapon, Pack, Protective Mask, etc.)

YES [3]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from wearing a Protective Mask?

YES [3]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from wearing All Chemical Defense Equipment?
If YES, what is the Medical Condition?

YES [3]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from doing 3-5 second Rushes under direct and indirect fire?

YES [3]

NO [1]
If YES, what is the Medical Condition?

Do you have any Medical Condition that might prevent Deployment?

YES [3]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from performing the Army Physical Fitness Test (APFT)
2 Mile Run?

YES [2]

NO [1]
If you cannot perform APFT 2 Mile Run, you must perform an Aerobic Alternate APFT:

Walk and/or Bicycle and/or Swim.

Indicate the Aerobic Alternate APFT Events you can perform
functional capacity certificate form 507
T Medical Facility) - 157th Air Refueling Wing, New Hampshire Ang ...
STANDARD FORM 507 (08-01) Prescribed by GSAICIMR, FlRMR (41-CFR) 201-9.202-1 (Computer generated by Pimr) Procedures for Completing the SF507 (usarj.army.mil)
U.s. Army Form Sf-507 - Convert Your Documents Into Pdf …
form number: form title: u.s. government agency: points of contact: users: file formats: optimized? printable? fillable? savable? obtaining from: issuances: (157arw.ang.af.mil)
507-109 Report On
This is a web-optimized version of this form. Download the original, full version: ... 507-109 . NSN 7540-00-634-4120 ; Report on ; MEDICAL RECORD : or Continuation of S.F. (usa-federal-forms.com)
.
WALK [2]
BICYCLE [2]
SWIM [2]
I cannot perform the APFT 2 Mile Run or any Aerobic Alternate APFT Events (Walk or Bicycle or Swim).

Do you have a Medical Condition that prevents you from doing APFT Push Ups?

YES [2]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from doing APFT Sit Ups?

YES [2]

NO [1]
If YES, what is the Medical Condition?

Do you have a Medical Condition that prevents you from doing Standard Aerobic Conditioning Activities?

YES [2]

NO [1]
If YES, what is the Medical Condition?

Indicate the Activity you CANNOT Do you have a Medical Condition that prevents you from doing Upper or Lower Body Weight Training?

YES [2]

NO [1] Name: 2 of 2
If YES, what is the Medical Condition? > Indicate the Activity you CANNOT perform:

Upper Body
Lower Body

Have you been treated for Any Mental Health Condition in the Past 5 Years?

YES [?]

NO [1]
If YES, what is the Mental Health Condition?

Have you been Diagnosed with Asthma?

If YES, Answer All Questions in # 20;

If No: Go to # 21

YES [?]

NO [1]
a.Have you been Admitted to a Hospital, Visited an Emergency Department or Lost Time From Work due to
Asthma and/or Asthma Related YES, how many Admissions?

_____ Emergency Department Visits?

_____ Lost Work Days?

_____

b.

Have you taken Oral and/or Inhaler Steroid Medications for your Asthma in past 12 mos?

YES

NO
If YES: How many times?

______ x

daily; ______ x

weekly; can use your inhaler beforehand, would your Asthma still prevent you from taking and passing the
APFT 2 Mile Run Event?
YES

NO
d.Does your Asthma prevent you from Wearing a Protective Mask?

YES

NO Do you have a Medical Condition that requires any Breathing Assist Device and/or Supplemental Oxygen?

YES [?]

NO [1]
If YES, what is the Medical Condition?

Do you take any Medication to Control your Blood Sugar?

YES [?]

NO [1]

If YES, indicate Medication Names:

Do you currently take Any Prescription and/or Non Prescription YES, Specify Medications and Medical Conditions:

Do you currently have a Permanent Profile?

If YES, what is the Date of Issue (month/day/year)?
YES

NO
What is the Medical Condition?

What are the Recommended Limitations?

Do you currently have a Temporary Profile?

If YES, what is the Date of Expiration (> What is the Medical Condition?
Afd 081002 034
Attacksoranginapriortoage55 ....Yes No you have jobs or hobbies which involve exposure to loud noises? .4.

Do you routinely forget to wear proper protective gear for sports (e.g.

goggles, ear plugs, gloves, ....routinely forget to fasten your seatbelt? you, or anyone you know, thought should cut down ...

prescription medications, over the counter drugs, or nutritional supplements to include herbs? .than one serving of high fat (e.g.red meat, eggs, cheese, chocolate, fried foods, ...)p erday? ..Since your last ...allergic reactions to food ..

hospitalized for at least 24 hours ....than the items listed above, please list any other medical treatment evaluation since your last examination.

To the best of NO OTHER significant medical surgical history has occured since my last examination.denies and medical record review reveals other significant medical history since last exam dated /.
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