4. Pertinent physical findings including: a. Results of tests performed on patient, including dates and specific findings:
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1 Medical Assessment Form Patient: SSN: Please answer each of the following questions about the patient. They concern the patient s claim of entitlement to disability benefits under the Social Security Act. Since this form will be used by the Social Security Administration in deciding if the patient is disabled, please make sure that it is legible and that every question is answered completely. If a question is not applicable to the patient, please so indicate. 1. Dates of treatment: First Last Frequency 2. Diagnoses: 3. Brief medical history: 4. Pertinent physical findings including: a. Results of tests performed on patient, including dates and specific findings: b. Clinical findings and observations: 1
2 5. Describe in detail the patient s symptoms (including fatigue, weakness, pain, nausea, vomiting, diarrhea, weight loss, insomnia, memory loss, concentration deficits, neuropathy, anemia, herpes outbreaks, etc.): 6. Is it reasonable to expect these symptoms given the objective medical findings? Yes No 7. Treatment and medications prescribed with dosage, frequency and response: 8. Does any medication have side effects or limit the patient s activities? Yes No. If yes, explain: 9. Have any of your patient s medical conditions lasted or can any be expected to last at least twelve months? Yes No 10. Prognosis: 11. Does or could any medical condition cause your patient pain? Yes No. If yes, explain: 12. Does the patient require a work accommodation to sit and stand at will due to pain? Yes No 13. Does the patient have to lie down during the day? Yes No If yes, for how long and for what reason: 2
3 14. Could your patient travel alone to work on a daily basis: (a) By bus? Yes No (b) By subway? Yes No 15. Please answer each question by estimating the degree of your patient s ability to do the following on a daily basis in a work place setting (taking into account pain and medication side effects): (a) In an 8-hour workday your patient can: Sit a total of hours in an 8-hour workday. Stand and/or Walk a total of hours in an 8-hour workday. 16. Please estimate the degree of your patient s ability to do the following on a daily basis in a work place setting (taking into account pain and medication side effects). Occasionally means 1% - 33%; Frequently means 34% - 66%; Continuously means 67% - 100% In an 8-hour workday your patient can: Lift: Up to Carry: Up to Stoop Kneel Crouch Crawl Climb Balance 3
4 Use hands and/or arms for repetitive action, such as: Handling (gross manipulation) Fingering (fine manipulation) Reaching (extending hands & arms in any direction) Pushing and Pulling of Arm Controls Use feet for repetitive movements, such as pushing and pulling of leg controls: Both 17. The patient has restrictions involving: None Mild Moderate Total Restriction Exposure to dusts, fumes, gases, noxious odors and poor ventilation Exposure to marked changes in temperature and humidity Being around moving machinery Unprotected heights Driving a motor vehicle Explain or add any other restrictions: 4
5 18. Does your patient demonstrate any emotional or mental limitations (such as anxiety, depression, decreased concentration, memory problems, insomnia, or appetite loss) which impact their medical condition? Please specify. Yes No 19. Does your patient have any physical or mental limitations, including the impact of pain, which could cause them to be off task during the course of an 8 hour workday? Yes No If yes, please indicate below the amount of an 8-hour workday that the patient can maintain attention/ concentration satisfactorily: 80% 90% 100% < 75% 20. Are your patient s limitations, when considered in combination, likely to produce good days and bad days? Yes No If yes, please estimate, on average, how many days per month your patient is likely to be absent from work as a result of the impairments, or as a result of necessary medical treatment: Never About 3 days per month About 1 day per month About 4 days per month About 2 days per month More than 4 days per month 21. Additional comments: Signature: Date: Printed Name: Hospital: Address: Phone: If form is not completed by a physician, please have supervising physician review and co-sign the form below. Signature: Date: Printed Name: Title: 5
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