| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
Dear Doctor: Please answer the following questions with regard to your patient's claim for Social Security disability benefits or Supplemental Security Income (SSI). Please base your answers on how your patient's medical conditions affect his or her ability to function. |
1. | Nature, frequency and length of contact: | |
| 2. | Please describe patient's systoms (including patient's reports of pain, dizziness, etc.): | |
| 3. | State all clinical findings and laboratory/test results (or enclose copy of same): | |
| 4. | Diagnosis: | |
| 5. | Treatment and response (including list of medications and their effect and side-effects): | |
| 6. | Prognosis: | |
| 7. | Has the patient's impairment lasted, or can it be expected to last, at least twelve months? Yes _____ No _____ | |
8. | Can the patient continuously stand for at least 6 of 8 hours? Yes _____ No _____ How long CAN the patient stand? ________________ | |
9. | Can the patient continuously sit upright for at least 6 of 8 hours? Yes ______ No ______ How long CAN the patient sit upright? ________________ | |
10. | If the answer to either number 8 or number 9 is NO, why is the patient unable to sit or stand? | |
11. | Does the patient have to lie down during the day? Yes ______ No ______ If yes, please explain why: | |
12. | How many city blocks can the patient walk without stopping? | |
13. | How many pounds can the patient frequently lift over an 8 hour period? ______ Less than 5 ______5-10 ______11-20 ______21-50 ______over 50 | |
14. | How many pounds can the patient frequently carry? ______ Less than 5 ______5-10 ______11-20 ______21-50 ______over 50 | |
15. | Does the patient have any problems performing such functions as grasping, pulling, pushing, or doing fine manipulations with his or her hands? | |
16. | Does the patient have any problems with the following movements? (Please indicate any applicable range of motion studies): Bending ______________________________________ Squatting ______________________________________ Kneeling ______________________________________ Turning any parts of the body ________________________ | |
| 17. | Is the patient able to travel alone? Yes _____ No ______ | |
18. | Are there any other factors affecting the patient's ability to work (e.g. exposure to fumes, gases; ability to tolerate heights; restriction of exposure to movin machinery)? | |
19. | If your patient complains of any pain, please indicate the nature and severity of the complaints and your opinion of the patient's credibility with respect to his or her complaints: If there is an objective basis for the patient's pain, give specific details for this basis (i.e. degenerative changes in the spine): | |
20. | Considering your diagnosis of the patient's condition and his/her prognosis, is the patient capable of returning to his/her past job? Yes _____ No _____ State why or why not: | |
21. | Considering the same factors, is there any work the patient is capable of? State why or why not: | |
If possible, please enclose copies of your clinical records on this patient. Use the space below for any additional comments you may have: | ||
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |