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Part 5: FUNCTIONAL ABILITIES
Please indicate your patient’s current physical abilities:
o Sedentary Duties: Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly
to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary Duties involve sitting most of the time, but may
involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other
sedentary criteria are met.
o Light Duties: Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5kg) of force frequently, and/or a
negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Duties. Light
Duties usually require walking or standing to a signiﬁcant degree. However, if the use of the arm and/or leg controls require exertion of
forces greater than that for Sedentary Duties and the worker sits most of the time, the job is rated Light Duties.
o Medium Duties: Exerting up to 50 pounds (22.7 kg) of force occasionally and/or up to 25 pounds (11.3kg) of force frequently, and/or
up to 10 pounds (4.5 kg) of force constantly to move objects.
o Heavy Duties: Exerting up to 100 pounds (45.4 kg) of force occasionally and/or up to 50 pounds (22.7 kg) of force frequently, and/or
up to 20 pounds (9.1 kg) of force constantly to move objects.
o Very Heavy Duties: Exerting in excess of 100 pounds (45.4 kg) of force occasionally and/or up to 50 pounds (22.7 kg) of force
frequently, and/or up to 20 pounds (9.1 kg) of force constantly to move objects.
What are the obstacles that are preventing a return to employment, if any? _________________________________________
In your opinion, what is the earliest date your patient will be able to return to work? _______________ (DD/MM/YYYY)
If the previous job could be modiﬁed, when could rehabilitative employment commence? _______________ (DD/MM/YYYY)
Driver’s license revoked: Yes
o No o If “Yes”, please provide date: _______________ (DD/MM/YYYY)
Part 6: COMPETENCY
Do you believe your patient is competent to endorse cheques and direct the use of the proceeds thereof? Yes o No o
If “No”, from what date? ________________________ (DD/MM/YYYY)
If “No”, have you referred the case to the Public Trustee, or has a Guardian been appointed, or is there a Power of Attorney?
Yes o No o
Part 7: COMMENTS
We would appreciate any additional comments that would help us to better understand your patient and his or her condition.
Signature Date (DD/MM/YYYY)
Physician’s Name (Please print) Degree and Specialty
o Primary Care o Consultant
Address (Street / City / Province / Postal Code)
Email Address: __________________________________________________________________________________________
Telephone No: ( ) ____________________________________ Fax No: ( ) ________________________________
Send the completed form and documents to our ofce by email: email@example.com
You can also fax the information to: RBC Life Insurance Company, Life and Health Claims Department, 1-800-714-8861.
If you have any questions, call toll free 1-877-519-9501 or 416-643-4700.
RBC Life Insurance Company, Life and Health Claims Department, P.O. Box 4435, Station A, Toronto ON, M5W 5Y8
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence. VPS107150
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