CARDIAC 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:

2. Diagnosis (with New York Heart Association functional classification):

3. Prognosis:

4. Identify clinical findings, laboratory and test results that show your patient’s impairments:

5. Identify your patient’s signs and symptoms:

6. If your patient has angina:

a. Describe nature, location and radiation of symptoms:

b. How often do angina episodes typically occur?

c. If your patient must typically rest after an episode of angina, how long will your patient typically rest?

7. Describe the treatment and response including any side effects of medication that may have implications for working, e.g., drowsiness, dizziness, nausea, etc:

8a. What is the role of stress in bringing on your patient’s symptoms?

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

Please explain the reasons for your conclusion:

9. Do your patient’s physical symptoms and limitations cause emotional difficulties such as depression or chronic anxiety?

Please explain:

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

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

12. 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 how long your patient can sit and stand/walk total in an 8-hour working day (with normal breaks):

Sit:

Stand/walk:

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

d. Will your patient sometimes need to take unscheduled breaks during a working day?

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 down or ̈ sit quietly?

e. 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?

3. what symptoms cause a need to elevate the leg(s)?

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.

f. 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.

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

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

h. State the degree to which your patient should avoid the following

Rows	No Restrictions	Avoid Concentrated Exposure	Avoid Even Moderate Exposure	Avoid All Exposure
Extreme Cold
Extreme Heat
High Humidity
Wetness
Cigarette Smoke
Perfumes
Soldering Fluxes
Solvents/ Cleaners
Fumes, Odors, gases
Dust
Chemicals

List other irritants:

ENVIRONMENTAL RESTRICTIONS

List other irritants:

ENVIRONMENTAL RESTRICTIONS

i. 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?

j. 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:

13. 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:

14. Please describe any other limitations (such as psychological limitations, limited vision, difficulty hearing, etc.) that would affect your patient’s ability to work at a regular job on a sustained basis:

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