Fibromyalgia MSS MEDICAL SOURCE STATEMENT/Impact Disability Law

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?

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?

6. Identify the clinical findings, laboratory and test results that show your patient’s medical Impairments:

7. Identify all of your patient's symptoms:

8. Do emotional factors contribute to the severity of your patient’s symptoms and functional limitations?

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:

Rows	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:

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.

c. Please indicate the hours and/or minutes that your patient can stand at one time, e.g., before needing to get up, etc.

d. Please indicate how long your patient can sit and stand/walk total in an 8-hour working day (with normal breaks):

Sit:

Stand/walk:

e. Does your patient need a job that permits shifting positions at will from sitting, standing or walking?

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

1. Approximately how often must your patient walk?

2. How long must your patient walk each time?

g. While engaging in occasional standing/walking, must your patient use a cane or other assistive device?

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

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?

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?

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

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

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

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

Rows	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:

Rows	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?

o. To what degree can your patient tolerate work stress?

p. Are your patient’s impairments likely to produce “good days” and “bad days”?

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:

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?

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.

Date:

Date

Signature

Printed/Typed Name:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

Fibromyalgia MEDICAL SOURCE STATEMENT