POST CANCER TREATMENT 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:

a. Please identify the type of cancer:

b. Cancer status:

Other

c. Does your patient have chronic fatigue as a result of cancer or treatment (including radiation and/or chemotherapy)?

d. Please identify your patient’s other impairments that could cause or exacerbate your patient’s chronic fatigue:

3. Other Diagnoses:

4. Prognosis:

5. Please list signs and symptoms (other than fatigue) your patient has as a result of cancer or treatment?

6. Identify any side effects of current medication that may have implications for working:

7. Have your patient’s impairments lasted or can they be expected to last at least twelve months?

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

9. Identify any psychological conditions affecting your patient’s physical condition:

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.

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. Is your patient capable of working an 8-hour working day, 40 hours per week?

Approximately how many hours per week can your patient work?

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

g. If your patient’s symptoms would likely cause the need to take unscheduled breaks to rest during a workday?

1) How many times during an average workday do you expect this to happen?

2) How long (on average) will your patient have to rest before returning to work?

3) What symptoms cause a need for breaks?

h. 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.

i. 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.

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

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

k. 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

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?

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

Please explain the reasons for your conclusion:

n. 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. The limitations above are assumed to be your opinion regarding current limitations only. However, if you have sufficient information to form an opinion within a reasonable degree of medical or psychological probability as to past limitations, on what date were the limitations you found above first present?

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.

Date:

Date

Signature

Printed/Typed Name:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

POST CANCER TREATMENT MEDICAL SOURCE STATEMENT

2. If your patient has been diagnosed with and treated for cancer,