☐ ☐ Rare Rare ☐ ☐ None None Constant ☐ Constant ☐ ☐ ☐ Frequent Frequent Climbing ☐ ☐ Climbing (Ladders): Occasional Occasional (Stairs): Rare ☐ Rare ☐ ☐ ☐ None None ☐ ☐ Constant Constant ☐ ☐ Frequent Frequent Occasional ☐ Occasional ☐ Bending: Pushing/Pulling: ☐ ☐ Rare Rare ☐ ☐ None None Constant ☐ Constant ☐ ☐ ☐ Frequent Frequent ☐ ☐ Driving: Occasional Crouching/Kneeling: Occasional ☐ ☐ Rare Rare None ☐ None ☐ ☐ ☐ Constant Constant ☐ ☐ Frequent Frequent ☐ ☐ Lifting: Occasional Carrying: Occasional Rare ☐ Rare ☐ ☐ ☐ None None ☐ ☐ Sitting: Constant Constant Fine Motor Coordination
Rare ☐ Rare ☐ None ☐ None ☐ Climbing (Ladders): Constant ☐ Climbing (Stairs): Constant ☐ Frequent ☐ Frequent ☐ Occasional ☐ Occasional ☐ Rare ☐ Rare ☐ None ☐ None ☐ Bending: Constant ☐ Pushing/Pulling: Constant ☐ Frequent ☐ Frequent ☐ Occasional ☐ Occasional ☐ Rare ☐ Rare ☐ None ☐ None ☐ Driving: Constant ☐ Crouching/Kneeling: Constant ☐ Frequent ☐ Frequent ☐ Occasional ☐ Occasional ☐ Rare ☐ Rare ☐ None ☐ None ☐ Lifting: Constant ☐ Carrying: Constant ☐ Frequent ☐ Frequent ☐ Occasional ☐ Occasional ☐ Rare ☐ Rare ☐ None ☐ None ☐ Sitting: Constant ☐ Fine Motor Coordination Constant ☐
Physician_WDP_Package.docx