MULTIPLE SCLEROSIS MEDICAL SOURCE STATEMENT/Impact Disability Law

MULTIPLE SCLEROSIS 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 have multiple sclerosis?

YesNo
How was this diagnosis made?
3. Prognosis:
4. Identify all of your patient’s symptoms and signs:

Chronic fatigueSensitivity to heatLoss of manual dexterityBalance problemsUnstable walkingPoor coordinationParesthesiasPainNumbnessParalysisMuscle spasticityMuscle atrophyWeaknessMuscle fatigue of limbStatic tremorIntention tremorCerebellar ataxiaSpeech difficultiesIncreased deep reflexesVertigoDimness of visionPain in one eyeNystagmusPartial blindnessBlurred visionDouble visionOther vision disturbanceBowel problemsBladder problemsProblems with judgmentDepressionEmotional labilityPersonality changeDifficulty rememberingConfusionDifficulty solving problems
Other symptoms, signs and clinical findings:
5. Have your patient’s impairments lasted or can they be expected to last at least twelve months?

YesNo
6. Does your patient have significant and persistent disorganization of motor function in two extremities resulting in sustained disturbance of gross and dexterous movement or gait and station?

YesNo
Please describe the degree of interference with locomotion and/or interference with the use of fingers, hands and arms:
7. Does your patient have significant reproducible fatigue of motor function with substantial muscle weakness on repetitive activity, demonstrated on physical examination, resulting from neurological dysfunction in areas of the central nervous system known to be pathologically involved by the multiple sclerosis process?

YesNo
Describe the degree of exercise and the severity of the resulting muscle weakness:
8a. During the past year what are the approximate dates of exacerbations of M.S.?
8b. Of the exacerbations listed above, pick the ones that would prevent any work for more than one month.
9. Does your patient complain of a type of fatigue that is best described as lassitude rather than fatigue of motor function?

YesNo
Is this kind of fatigue complaint typical of M.S. patients?

YesNo
10. 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. 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. What symptoms cause a need for breaks?

Muscle weaknessPain/ paresthesias, numbnessChronic fatigueAdverse effects of medicationOther
g. 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?
3. What symptoms cause a need to elevate the leg(s)?
h. While engaging in occasional standing/walking, must your patient use a cane or other hand-held assistive device?

YesNo
What symptoms cause a need to use a cane?

Muscle weaknessSpasticityChronic fatigueIncoordinationImbalanceOther

i. 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.

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

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

k. If your patient has significant limitations with reaching, handling or fingering:
What symptoms cause limitations of use of the upper extremities?

Pain/ paresthesiasIncoordinationSensory loss/ numbnessMuscle weaknessSpasticityFatigueTremorOther

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

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

YesNo
n. 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
Please explain the reasons for your conclusion:
o. 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
11. 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:
12. Please describe any other limitations (such as psychological limitations, limited vision, difficulty hearing, difficulty speaking, need to avoid temperature extremes, wetness, humidity, noises, dust, fumes, gases or hazards, etc.) that would affect your patient’s ability to work at a regular job on a sustained basis.
13. What is the earliest date that the description of symptoms and limitations in this questionnaire applies?

MonthDayYear
Date
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

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Printed/Typed Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

MULTIPLE SCLEROSIS MEDICAL SOURCE STATEMENT

k. If your patient has significant limitations with reaching, handling or fingering: