Functional Limitations. A series of questions pertained to functional limitations, defined as difficulty in performing certain specific physical actions. WLKLIM13 was the filter question. It was derived from a question (HE09) that was asked at the family level: Does anyone in the family have difficulties walking, climbing stairs, grasping objects, reaching overhead, lifting, bending or stooping, or standing for long periods of time? If the answer was “no”, then all family members were coded as “no” (2) on WLKLIM13. If the answer was “yes”, then the specific persons who had any of these difficulties were identified and coded as “yes” (1) on WLKLIM13, and remaining family members were coded as “no”. If the response to the family-level question was “don’t know” (-8), “refused” (-7), “missing” (-9), or “Inapplicable” (-1), then the corresponding missing value code was applied to each family member’s value for WLKLIM13. If the answer to HE09 was “yes”, but no specific individual was named as experiencing such difficulties, then each family member was assigned -8 for WLKLIM13. Deceased persons were assigned a code of “Inapplicable” (-1) for WLKLIM13. If any family member was coded “yes” to WLKLIM13, a subsequent series of questions was administered. The series of questions for which WLKLIM13 served as a filter was as follows: LFTDIF13 – difficulty lifting 10 pounds STPDIF13 – difficulty walking up 10 steps WLKDIF13 – difficulty walking 3 blocks MILDIF13 – difficulty walking a mile STNDIF13 – difficulty standing 20 minutes BENDIF13 – difficulty bending or stooping RCHDIF13 – difficulty reaching over head FNGRDF13 – difficulty using fingers to grasp This series of questions was asked separately for each person who was coded “yes” to WLKLIM13. This series of questions was not asked for other individual family members for whom WLKLIM13 was “no”. In addition, this series was not asked about family members who were less than 13 years of age, regardless of their status on WLKLIM13. These questions were not asked about deceased family members. In such cases (i.e., WLKLIM13 = 2, or age < 13, or PSTAT13 = (23,24,31)), each question in the series was coded as “Inapplicable” (-1). Finally, if responses to WLKLIM13 were “refused” (-7), “don’t know” (-8), “not ascertained” (-9), or otherwise Inapplicable (-1), then each question in this series was coded as “Inapplicable” (-1). Analysts should note that, for WLKLIM13, there was no minimum age criterion that was used to determine a skip pattern, where...
Functional Limitations. Restrictions/limitations of function resulting from medications and/or treatment and approximate duration: Are there any medical restrictions that limit your patient’s functions or abilities? No Yes – please complete below. * PLEASE NOTE THAT TRANSITIONAL WORK IS AVAILABLE Physical Limitations: Duration – Comments Walking: Standing: Sitting: short distances only less than 15 min. less than 30 min. medium distances less than 30 min. less than 1 hr. no restriction no restriction no restriction Lifting Floor to Waist: Lifting Waist to Shoulder: Stair Climbing: none Ladder Climbing: none Hand / Wrist: grip <10 kg <10 kg 2-3 steps 2-3 steps type <25 kg <25 kg short flight 4-6 steps write no restriction no restriction no restriction no restriction no restriction Above Shoulder Activity: Below Shoulder Activity: Vision: acuity depth perception Pushing / Pulling: Other: Cognitive/Mental Limitations: Duration – Comments Attention & Concentration: mild moderate severe Learning & Memory: mild moderate severe Decision-Making: mild moderate severe Judgment: mild moderate severe Organization & Planning: mild moderate severe Social Interaction: mild moderate severe Communication: mild moderate severe Adaptation: mild moderate severe Other: PATIENT: PHYSICIAN INFORMATION Name of Attending Physician (please print) Specialty (if applicable) Address City, Province, Postal Code ( ) ( ) Phone Number Fax Number Physician’s Signature Date: (month, day, year) * Please fax or mail this form by: * In accordance with the BCMA fee schedule A00032, Healthcare Benefit Trust will pay a form completion fee of $37.50 for your assistance in this regard. Please mail your invoice to the address listed below. Please note we require original form fee invoices (not faxes). *************************************************************************************************** Fax to: Early Intervention Coordinator Fax: 000-000-0000 Early Intervention Services HEALTHCARE BENEFIT TRUST #000 - 0000 Xxxx Xxxxxxxx Xxxxxxxxx, XX X0X 0X0 Telephone: 000-000-0000 Toll Free: 0-000-000-0000 *************************************************************************************************** Appendix D – Reminder Letter Dear (Employee): RE: Reminder Letter Employee Reference #: Union Name, (Health Authority, Job Site) I am writing to let you know that we have not yet received your Authorization and Occupational Fitness Assessment forms. This information is required in order to participate in the Early Interventio...
