BREAST CANCER TREATING PHYSICIAN DATA SHEET/Impact Disability Law

BREAST CANCER TREATING PHYSICIAN DATA SHEET
From:
Re: Name of Patient
Note 1: This document will not have legal validity for Social Security disability determination purposes unless completed by a licensed medical doctor or osteopath.

Note 2: This document only concerns breast cancer in adults. Other impairments and limitations resulting from a combination of impairments should be considered separately.

Note 3: Age, degree of general physical conditioning, sex, body habitus (i.e., natural body build, physique, constitution, size, and weight), insofar as they are unrelated to the patient’s medical disorder and symptoms, should not be considered when assessing the functional severity of the impairment.

“Occasionally” means very little up to 1/3 of an 8 hour workday.

“Frequently” means 1/3 to 2/3 of an 8 hour workday.

“Inoperable” means that surgery is of no therapeutic value or cannot be performed for medical reasons.

“Metastases” means spread by body fluid, such as hematogenous or lymphatic, not including direct extension.

“Persistent” means failure to achieve a complete remission.

“Progressive” means the malignancy becomes more extensive after treatment.

“Recurrent, relapse” means a cancer that was in complete remission or entirely removed by surgery has returned.

“Unresectable” means surgery was performed but malignant tumor was not removed. This terms includes situations in which the tumor is incompletely resected or the surgical margins are positive. It does not include situations in which a tumor is completely resected but the patient is receiving adjuvant therapy, such as post-operative chemotherapy or radiation.
What is the specific diagnosis?

Left breastRight breastBilateral primariesCarcinoma in-situInflammatory carcinomaDirect extension to chest wall or skin
II. Please specify the following dates in regard to the original myeloma:
Date you first saw patient:

MonthDayYear
Date
Date patient gave as symptom onset:

MonthDayYear
Date
Date of original diagnosis:

MonthDayYear
Date
III. Treatment (Please check all that apply.)
A. Type of antineoplastic therapy

SurgeryRadiationChemotherapyHormonal therapyOther
B. Persistent,unresectable, or inoperable disease currently?

YesNoUnknown
Explain:
C. Progressive disease despite therapy?

YesNoUnknown
Where?
D. Please provide the following information:
1. If applicable, please provide names of drugs, dosages, frequency of administration, and plans for continued administration.
2. If the patient had surgery for breast cancer, please describe extent of surgery or attach operative notes.
3. If the patient had radiation therapy, please describe schedule and radiation fields.
IV. Metastases anywhere?

YesNoUnknown
Supraclavicular nodesInfraclavicular nodesAxillary nodesIpsilateral internal mammary nodesTen or more axillary nodesDistant metastasis
V. Imaging done?

YesNoUnknown
CTMRIPETPlain X-rayUltrasound
Please specify location(s) of involvement:
VI. Does the patient have recurrent breast cancer?

YesNoUnknown
Please give the date of diagnosis recurrence:

MonthDayYear
Date
How was the recurrence diagnosed:

BiopsyImaging
Specific imaging type:
What was the location of recurrence?

Local recurrence, remitted with antineoplastic therapyLocal recurrence, did not remit with antineoplastic therapyMetastatic recurrence, any non-local
Briefly describe location of recurrence:
VII. Residual Functional Capacity. If (1) inflammatory carcinoma, or (2) extension to chest wall or skin or (3) metastasis to ipsilateral internal mammary nodes, supra- or infraclavicular nodes, 10 or more axillary nodes, or distant metastasis, or (4) any recurrent carcinoma except local cancer that responds to treatment, AND it has been less than 3 years from last evidence of cancer, skip and check here.
Questions answered on another form.
1. Does the patient have the ability to stand and/or walk 6 – 8 hours daily on a long-term basis?

YesNoUnknown
How long can the patient stand and/or walk (with normal breaks) in a 6 – 8 hour work day?
2. What maximum weight can the patient lift and/or carry occasionally (cumulatively not continuously)?

Less than 10 lbs.10 lbs.20 lbs.50 lbs.100 lbs.UnknownOther (lbs.)
3. What weight can the patient lift and/or carry frequently (cumulatively not continuously)?

Less than 10 lbs.10 lbs.20 lbs.50 lbs. or moreUnknownOther (lbs.)
5. Specific types of extremity exertion: Can the following activities be performed?
Pushing or pulling:

neveroccasionallyfrequentlyUnknown
Climbing:

neveroccasionallyfrequentlyUnknown
Overhead work:

neveroccasionallyfrequentlyUnknown
VIII. Additional physician comments. (Also list other disorders of which you are aware.)
Answered on another form.
Comments
Attach all relevant treatment notes, laboratory and test results, which have not been provided previously to the Social Security Administration.

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Physician’s Name (print or type)

First NameLast Name
Physician’s Signature (no name stamps)

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Date

MonthDayYear
Date
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