CIRRHOSIS/LIVER DISEASE MEDICAL ASSESSMENT FORM/Impact Disability Law

CIRRHOSIS/LIVER DISEASE MEDICAL ASSESSMENT FORM
From:
Re: Name of Patient
Please answer all the following questions concerning your patient’s cirrhosis and other health problems. Attach all relevant treatment notes, laboratory and test results, which have not been provided previously to the Social Security Administration.
1. Date began treatment

MonthDayYear
Date
Frequency of tx:
2. Does your patient exhibit cirrhosis?

YesNo
What classification of cirrhosis does your patient exhibit?

micronodularmacronodularmixedOther
3. Identify any symptoms or signs that your patient exhibits due to his/her impairments:

weaknessjaundicesleep disturbanceemesispleural effusionsrecurrent/persistent diarrhearecurrent fevershot/cold spellsspider neviasteixistremordysarthriacholangitissplenomegalyanemiaecchymoticlesionschronic fatiguebowel incontinencerecurrent dizzy spellshistory of variceshematemesisrecurrent nausea/vomitingascitesperipheral edemaencephalopathy with day/night reversalpoor appetite with weight lossradiation of abdominal pain to the backurinary frequency/incontinencepersistent/recurrent abdominal pain, cramping and tendernesshistory of hepatocellura insulthepatitisspontaneous bacterial peritonitisOther
Hepatitis type:

ABC
4. Identify positive clinical findings and test results (e.g., lab abnormalities, biopsy, ultrasound, barium studies, MRI, CT):
5. Has your patient been referred for liver transplant?

YesNo
6. Does your patient currently abuse alcohol or street drugs?

YesNo
To the best of your knowledge, when was the last time your patient abused alcohol or street drugs?

NeverOther
If you were to assume that your patient was able to maintain complete sobriety, would your patient continue to exhibit the symptoms and limitations discussed in this form?

YesNo
Please explain:
7. Does your patient experience symptoms which interfere with the attention and concentration needed to perform even simple work tasks, so that if your patient was working s/he would likely be “off task” at least 15% of the time?

YesNo
8. If your patient was placed in a competitive job, identify those aspects of workplace stress that your patient would be unable to perform or be exposed to:

routine, repetitive tasks at consistent pacedetailed or complicated tasksfrequent interference with coworkers/supervisors/publicfast paced tasks (e.g., production line)
9. Identify any side effects of any medications which may have implications for working:

drowsiness/sedationOther
10. As a result of your patient’s impairment(s), estimate your patient’s functional limitations assuming your patient was placed in a competitive work situation on an ongoing basis:
A. How many city blocks can the patient walk without rest or severe pain?
B. Please select the hours and/or minutes that your patient can continuously sit and stand at one time:
1. Sit:

0 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes1 Hour2 HoursMore than 2 Hours
What must your patient usually do after sitting this long?

walkstandlie downOther
2. Stand:

0 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes1 Hour2 HoursMore than 2 Hours
What must your patient usually do after standing this long?

walksitlie downOther
C. Please indicate how long your patient can sit and stand/walk total in an eight hour work 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
D. Due to your patient’s impairment(s), if your patient will sometimes need to take unscheduled breaks (for at least several minutes duration) during an average eight-hour workday, how many times during an average workday do you expect this to happen?

012345678910more than 10
E. Due to your patient’s symptoms, should your patient elevate leg(s) at least two hours during a typical eight-hour daytime period?

YesNo
How high should leg(s) typically be elevated:

at or above heart levelwaist levelbetween heart and waist levelbelow waist level

F. How many pounds can the 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. Imagine that your patient was hired to perform competitive full-time work. Please estimate, on average, how often your patient would experience “bad days” so that your patient would be absent from work as a result of the impairment(s) or treatment:

never/less than once a monthabout four days a monthabout once or twice a monthmore than four days a monthabout three days a month
12. Please describe any other limitations that would affect your patient’s ability to work at a regular job on a sustained basis or any testing that would help to clarify the severity of your patient’s impairment(s) or limitations:
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
Signed:
Print Name:
Should be Empty: