HIDRADENITIS SUPPURATIVA MEDICAL SOURCE STATEMENT/Impact Disability Law

HIDRADENITIS SUPPURATIVA 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. Diagnoses:
3. Prognosis:
Other symptoms:
4. Identify symptoms your patient has had in the past two years:
Skin lesions that interfere with motion of

one jointtwo or more joints
Skin lesions that interfere with use of

one extremitytwo extremities
Skin lesions affecting

one axillaeboth axillae
Skin lesions affecting

one inguinal areaboth inguinal area(s)
Other symptoms:
5. Approximate frequency and duration of flare-ups:
6. Describe skin lesions:
7. Describe the treatment and response including any side effects of medication that may have implications for working, e.g., drowsiness, dizziness, nausea, etc:
8. Does your patient have extensive skin lesions that persist for at least 3 months despite continuing treatment as prescribed?

YesNo
9. 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. 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
b. Please circle 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 HourMore than 2 hour
c. Please select the hours and/or minutes that your patient can stand at one time, e.g., before needing to sit down, walk around, etc.

0 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes1 Hour2 HourMore than 2 hour

d. 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

e. 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
f. 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 downsit quietly
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.
Cancelof
Date:

MonthDayYear
Date
Signature
Printed/Typed Name:
Address

Street Address

Street Address Line 2

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Postal / Zip Code
Should be Empty:

HIDRADENITIS SUPPURATIVA MEDICAL SOURCE STATEMENT

4. Identify symptoms your patient has had in the past two years: