| 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. Please base your answers on how your patient's medical conditions affect his/her ability to function. |
| 1. | Nature, frequency and length of contact: | |
| 2. | Based on your physical examination of this patient, please describe any and all signs and symptoms indicative of a spinal disorder, particularly pain and muscle spasms. | |
| 3. | Diagnosis: | |
| 4. | Describe in degrees any limitation of motion of the patient's spine: | |
| 5. | Describe any motor loss and the radicular distribution of that motor loss: | |
| 6. | Describe in detail any muscle weakness associated with the spinal disorder: | |
| 7. | Describe any sensory and reflex loss associated with the spinal disorder: | |
| 8. | Please list the names and dates, and results of any and all clinical tests upon which you have based your diagnosis of this patient (e.g. CAT scan, x-rays, mylegrams): | |
| 9. | Treatment and responses, including list of medications prescribed and their side effects: | |
| 10. | Prognosis: | |
| 11. | Has the patient's impairment lasted or can it be expected to last at least 12 months? Yes _____ No ______ | |
| 12. | How long can the patient continuously stand? _______________________ | |
13. | How long can the patient continuously sit? ________________________ | |
14. | How long can the patient alternately sit or stand at one time? _________________ | |
| 15. | Does the patient have to lie down during the day? ______________ If yes, please explain: | |
| 16. | How many blocks can the patient walk without stopping? | |
| 17. | How many pounds can the patient lift? (Circle one) None up to 10 lbs. 11-20 lbs. 21-50 lbs. over 50 lbs. | |
| 18. | How many pounds can the patient carry? (Circle one) None up to 10 lbs. 11-20 lbs. 21-50 lbs. over 50 lbs. | |
| 19. | Does the patient have any problems bending, squatting, kneeling or turning parts of his/her body? If yes, please explain. (Please give results of any relevant range of motion studies.): | |
| 20. | Is patient able to travel alone by bus? _________ subway? __________ | |
| 21. | In your opinion, to a reasonable degree of medical certainty, does this patient suffer from an impairment which significantly limits his/her physical or mental ability to do basic work activities? | |
| 22. | Can this impairment be reasonably expected to produce the type of pain this patient complains of? | |
| Additional Comments | ||
| Signature: | ______________________________ |
| Name: (Print) | ______________________________ |
| Address: | ______________________________ ______________________________ |
| Telephone: | ______________________________ |