VISION IMPAIRMENT MEDICAL SOURCE STATEMENT/Impact Disability Law

VISION IMPAIRMENT MEDICAL SOURCE STATEMENT
From:
Re: Name of Patient
Please answer the following questions concerning your patient’s vision. Attach relevant treatment notes, laboratory and test results as appropriate.
Please answer the following questions concerning your patient’s impairments.
1. Frequency and length of contact:
2. Diagnoses:
3. Prognosis:
4. Visual acuity after best correction right eye:
5. Visual acuity after best correction left eye:
6. Describe any contraction of peripheral visual fields:
7. Describe your patient’s vision symptoms:
“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.
8. As a result of your patient’s impairments, estimate your patient’s vision limitations if your patient were placed in a competitive work situation.

a. How often can your patient perform work activities involving the following?

Rows	Never	Rarely	Occasionally	Frequently	Constantly
Near Acuity
Far Acuity
Depth Perception
Accommodation
Color Vision
Field of Vision

b. Is your patient capable of avoiding ordinary hazards in the workplace, such as boxes on the floor, doors ajar, approaching people or vehicles?

YesNo
c. Does your patient have any difficulty walking up or down stairs?

YesNo
d. Can your patient work with small objects such as those involved in doing sedentary work?

YesNo
e. Can your patient work with large objects?

YesNo
9. Please identify any exertional limitations; and please explain the relationship of these limitations to your patient’s vision:
a. How many pounds can your patient lift and carry in a competitive work situation?
Less than 10 lbs.

NeverRarelyOccasionallyFrequently
10 lbs.

NeverRarelyOccasionallyFrequently
20 lbs.

NeverRarelyOccasionallyFrequently
50 lbs.

NeverRarelyOccasionallyFrequently
b. How often can your patient perform the following activities?
Stoop (bend)

NeverRarelyOccasionallyFrequently
Crouch/ squat

NeverRarelyOccasionallyFrequently
c. Please explain the medical basis for the above limitations and whether they are related to your patient’s eye problem:
10. Will your patient sometimes need to take unscheduled breaks during an 8-hour 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) please explain why such breaks are necessary:
11. 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
12. Please describe any other limitations that would affect your patient’s ability to work at a regular job on a sustained basis:
13. Have your patient’s impairments lasted or can they be expected to last at least twelve months?

YesNo
Attach relevant treatment notes, laboratory and test results as appropriate.

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Note: Template was prepared by Liner Legal, LLC, but completed by signatory in compliance with SSA Rules and Regulations
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VISION IMPAIRMENT MEDICAL SOURCE STATEMENT

Please answer the following questions concerning your patient’s impairments.

“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.

9. Please identify any exertional limitations; and please explain the relationship of these limitations to your patient’s vision: