PHYSICAL MEDICAL SOURCE STATEMENT/Impact Disability Law

PHYSICAL MEDICAL SOURCE STATEMENT
From: Doctor/Practice Name
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. Diagnoses:
3. Prognosis:
4. List your patient’s symptoms, including pain, dizziness, fatigue, etc:
5. If your patient has pain, characterize the nature, location, frequency, precipitating factors, and severity of your patient’s pain:
6. Identify the clinical findings and objective signs:
7. Describe the treatment and response including any side effects of medication that may have implications for working, e.g., drowsiness, dizziness, nausea, etc:
8. 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. Please indicate the hours and/or minutes that your patient can sit at one time, e.g., before needing to get up, etc.

1 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes60 Minutes90 Minutes120 Minutes
b. Please indicate the hours and/or minutes that your patient can stand at one time, e.g., before needing to sit down, etc.

1 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes60 Minutes90 Minutes120 Minutes
c. Please indicate how long your patient can sit and stand/walk total in an 8-hour working 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. Does your patient need to include periods of walking around during an 8-hour working day?

YesNo
1. Approximately how often must your patient walk?

1 Minutes5 Minutes10 Minutes15 Minutes20 Minutes30 Minutes45 Minutes60 Minutes90 Minutes
2. How long must your patient walk each time?

1 Minutes2 Minutes3 Minutes4 Minutes5 Minutes6 Minutes7 Minutes8 Minutes9 Minutes10 Minutes11 Minutes12 Minutes13 Minutes14 Minutes15 Minutes
e. Will your patient sometimes need to take unscheduled breaks during a 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. what symptoms cause a need for breaks?

Muscle weaknessPain/ paresthesias, numbnessChronic fatigueAdverse effects of medicationOther
f. Should your patient’s leg(s) be elevated?

YesNo
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 leg(s)?
g. Must your patient use a cane or other hand-held assistive device?

YesNo
What symptoms cause the need for a cane?

ImbalancePainWeaknessInsecurityDizzinessOther
Does your patient need a cane or other hand-held assistive device for walking, standing or both?
Does your patient need a cane or other hand-held assistive device all of the time?
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.

h. 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.

i. Does your patient have significant limitations with reaching, handling or fingering?

YesNo

j. 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
k. To what degree can your patient tolerate work stress?

Incapable of even "low stress" workCapable of low stress workCapable of moderate stress - normal workCapable of high stress work
Please explain the reasons for your conclusion:
l. Are your patient’s impairments likely to produce “good days” and “bad days”?

YesNo
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:

NeverAbout three days per monthAbout one day per monthAbout four days per monthAbout two days per monthMore than four days per month
9. 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?

YesNo
Please explain:
10. Please describe any other limitations (such as psychological limitations, limited vision, difficulty hearing, need to avoid temperature extremes, wetness, humidity, noise, dust, fumes, gases or hazards, 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.
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Date:

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Date
Signature
Printed/Typed Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Note: Template was prepared by Impact Disability Law, but completed by signatory in compliance with SSA Rules and Regulations.
Should be Empty:

Rows	HANDS: Grasp, Turn Twist Objects	FINGERS: Fine Manipulations	ARMS: Reaching In Front of Body	ARMS: Reaching Overhead
Right
Left