Fibromyalgia MSS MEDICAL SOURCE STATEMENT/Impact Disability Law

Fibromyalgia MEDICAL SOURCE STATEMENT
From:
Re: Name of Patient
Please answer the following questions concerning your patient’s impairments. Attach relevant treatment notes, radiologist reports, laboratory and test results as appropriate.
1. Frequency and length of contact:
2. Does your patient meet the American College of Rheumatology criteria for fibromyalgia?

YesNo
3. List any other diagnosed impairments:
4. Prognosis:
5. Have your patient’s impairments lasted or can they be expected to last at least twelve months?

YesNo
6. Identify the clinical findings, laboratory and test results that show your patient’s medical Impairments:
7. Identify all of your patient's symptoms:

Multiple tender pointsNumbness and tinglingChronic fatigueRaynaud's PhenomenonMorning stiffnessDysmenorrheaSubjective swellingAnxietyIrritable Bowel SyndromePanic attacksFrequent, severe headachesDepressionFemale Urethral SyndromeMitral Valve ProlapsePremenstrual Syndrome (PMS)HypothyroidismVestibular dysfunctionCarpal Tunnel SyndromeTemporomandibular Joint Dysfunction (TMJ)Chronic Fatigue Syndrome
8. Do emotional factors contribute to the severity of your patient’s symptoms and functional limitations?

YesNo
9. If your patient has pain:

a. Identify the location of pain including, where appropriate, an indication of right or left side or bilateral areas affected:

	RIGHT	LEFT	BILATERAL
Lumbosacral spine
Cervical spine
Thoracic spine
Chest
Shoulders
Arms
Hands/fingers
Hips
Legs
Knees/ankles/feet

b. Describe the nature, frequency, and severity of your patient’s pain:
c. Identify any factors that precipitate pain:

Changing weatherFatigueMovement/OveruseColdStressHormonal ChangesStatic Position
10. Identify the side effects of any medication that may have implications for working, e.g., dizziness, drowsiness, stomach upset, etc.:
11. As a result of your patient’s impairments, estimate your patient’s functional limitations if your patient were placed in a competitive work situation.
a. How many city blocks can your patient walk without rest or severe pain?
b. Please indicate the hours and/or minutes that your patient can sit at one time, e.g., before needing to get up, etc.

0 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes1 Hour2 HoursMore than 2 Hours
c. Please indicate the hours and/or minutes that your patient can stand at one time, e.g., before needing to get up, etc.

0 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes1 Hour2 HoursMore than 2 Hours
d. Please indicate how long your patient can sit and stand/walk total in an 8-hour working day (with normal breaks):
Sit:

less than 2 hoursabout 2 hoursabout 4 hoursat least 6 hours
Stand/walk:

less than 2 hoursabout 2 hoursabout 4 hoursat least 6 hours
e. Does your patient need a job that permits shifting positions at will from sitting, standing or walking?

YesNo
f. Does your patient need to include periods of walking around during an 8-hour working day?

YesNo
1. Approximately how often must your patient walk?

1 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes60 Minutes90 Minutes
2. How long must your patient walk each time?

1 Minutes2 Minutes3 Minutes4 Minutes5 Minutes6 Minutes7 Minutes8 Minutes9 Minutes10 Minutes11 Minutes12 Minutes13 Minutes14 Minutes15 Minutes
g. While engaging in occasional standing/walking, must your patient use a cane or other assistive device?

YesNo
h. Will your patient sometimes need to take unscheduled breaks during a working day?

YesNo
1. how often do you think this will happen?
2. how long (on average) will your patient have to rest before returning to work?
3. on such a break, will your patient need to ̈ lie down or ̈ sit quietly?
i. With prolonged sitting, should your patient’s leg(s) be elevated?

YesNo
1. how high should the leg(s) be elevated?
2. if your patient had a sedentary job, what percentage of time during an 8-hour working day should the leg(s) be elevated?
For this and other questions on this form, “rarely” means 1% to 5% of an 8-hour working day; “occasionally” means 6% to 33% of an 8-hour working day; “frequently” means 34% to 66% of an 8-hour working day.

j. How many pounds can your patient lift and carry in a competitive work situation?

	Never	Rarely	Occasionally	Frequently
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.

k. How often can your patient perform the following activities?

	Never	Rarely	Occasionally	Frequently
Twist
stoop (bend)
Crouch/ Squat
Climb Stairs
Climb Ladders

l. How often can your patient perform the following activities?

	Never	Rarely	Occasionally	Frequently
Look down (sustained flexion of neck)
Turn head right or left
Look up
Hold head in static position

m. If your patient has significant limitations with reaching, handling or fingering, please indicate the percentage of time during an 8-hour working day that your patient can use hands/fingers/arms for the following activities:

	HANDS: Grasp, Turn Twist Objects	FINGERS: Fine Manipulations	ARMS: Reaching In Front of Body	ARMS: Reaching Overhead
Right
Left

n. How much is your patient likely to be “off task”? That is, what percentage of a typical workday would your patient’s symptoms likely be severe enough to interfere with attention and concentration needed to perform even simple work tasks?

0%5%10%15%20%25% or more
o. To what degree can your patient tolerate work stress?

Incapable of even "low stress" workCapable of low stress workCapable of moderate stress - normal workCapable of high stress work
p. Are your patient’s impairments likely to produce “good days” and “bad days”?

YesNo
Assuming your patient was trying to work full time, please estimate, on the average, how many days per month your patient is likely to be absent from work as a result of the impairments or treatment:

NeverAbout three days per monthAbout one day per monthAbout four days per monthAbout two days per monthMore than four days per month
12. Are your patient’s impairments (physical impairments plus any emotional impairments) as demonstrated by signs, clinical findings and laboratory or test results reasonably consistent with the symptoms and functional limitations described above in this evaluation?

YesNo
Please explain:
13. Please describe any other limitations (such as psychological limitations, limited vision, difficulty hearing, etc.) that would affect your patient’s ability to work at a regular job on a sustained basis:
Attach all relevant treatment notes, laboratory and test results, which have not been provided previously to the Social Security Administration.

You can upload multiple files at a time.
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Address

Street Address

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Note: Template was prepared by Impact Disability Law, but completed by signatory in compliance with SSA Rules and Regulations.
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Fibromyalgia MEDICAL SOURCE STATEMENT