Physical & Mental Combined Residual Functional Capacity Report
Physical & Mental Combined Residual Functional Capacity Report
Physical & Mental Combined Residual Functional Capacity Report
SS#: _______________________
Please answer the following questions concerning your patient=s impairments. Attach all relevant treatment notes, radiologist reports,
laboratory and test results that have not been provided previously to the Social Security Administration.
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Depression
Psychological factors affecting physical condition Other:
12. Are your patient”s impairments (physical impairments plus any emotional impairments) reasonably
consistent with the symptoms and functional limitations described in the evaluation? yes
no
13. To what degree can your patient tolerate work stress (i.e., maintain persistence and pace required
within the confines of a competitive work environment) ?
Incapable of even “low stress” jobs Capable of low stress
jobs Moderate
stress is
Capable of high stress work
okay
14. As a result of your patient’s impairments, estimate your patient’s functional limitations if your
patient were placed in a hypothetical competitive work situation.
a. How many city blocks can your patient walk without rest or severe pain?
b. Please circle the hours and/or minutes that your patient can sit at one time, e.g., before
needing to get up, etc.:
Sit: 0 5 10 15 20 30 45 Minutes 1 2 More than 2 Hours
c. Please circle the hours and/or minutes that your patient can stand at one time, e.g.,
before needing to sit down, walk around, etc.
Stand: 0 5 10 15 20 30 45 Minutes 1 2 More than 2
Hours
d. Please indicate how long your patient can sit and stand/walk total in an 8-hour working
day (with normal breaks)
Sit Stand/walk
less
than 2 hours
about 2
hours
about 4
hours
at least
6 hours
e. Does Pt need to include periods of walking around during an 8hr working day? Yes
2
No
1) If yes, approximately how often must your patient walk?
1 5 10 15 20 30 45 60 90 Minutes
2) How long must your patient walk each time?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Minutes
f. Does your patient need a job that permits shifting positions at will from sitting, standing or
walking? Yes No
g. Will your patient sometimes need to take unscheduled breaks during an 8-hour working
day? Yes No
If yes, 1) how often do you think this will happen?
2) how long (on average) will your patient have to rest before returning
to
work? _____________________________________
h. With prolonged
sitting, should
your patient’s
leg(s) be
elevated?
Yes
No
If yes, 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? __________
i. While engaging in occasional standing/walking, must your patient use a cane or other
assistive device? Yes No
Regarding the questions contained within 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.
15. a. How often during a typical workday is your patient=s experience of pain or other
symptoms severe enough to interfere with attention and concentration needed to perform
even simple tasks?
Never Rarely Occasionally Frequently Constantly
b. How many pounds can your patient lift and carry in a competitive work situation?
Never Rarely Occasionally Frequently
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Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
c. How often can your patient perform the following activities?
Never Rarely Occasionally
Frequently
Look down (sustained)
Turn head right or left
Look up
Hold head in static position
f. How often can the individual perform the following Physical Functions ?
Never Rarely Occasionally Frequently
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Reaching
Handling
Feeling
Pushing/Pulling
Hearing
Speaking
g. Are your patient’s impairments likely to produce “good days” and “bad days”? Yes No
If yes, 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.
never about three
days per month
about one day per month about four days per month
about two days per month more than four days per month
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h. Please place an appropriate number in boxes for any Environmental Restrictions caused by
the impairments or check the No box:
1 = Avoid ALL Exposure; 2 = Avoid CONCENTRATED Exposure; 3 = Avoid Even MODERATE Exposure
Heights Chemicals
Vibrations Dryness
Noise Temperature
Extremes
Perfumes Cigarette
Smoke
Chemicals Other
(specify):
16. 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:
______________________________________________________________________________
___________________________________________________________________________
17. Based on the Claimant’s medical history and/or clinical presentation what is the earliest date that
the description of symptoms and limitations in this questionnaire applies?
_____________________
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Please answer the following questions concerning your patient’s impairments. Attach all relevant treatment notes and test
results that have not been provided previously to the Social Security Administration.
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1. a. Assessment is from _______ to ____________________________
b. Specify the listing(s) (i.e., 12.02 through 12.10) under which the items below are being rated (check appropriate box to
reflect the category(ies) upon which the medical disposition is based: Indicate to what degree the following functional
limitations (which are found in paragraph B of listings 12.02-12.04, 12.06-12.08 and 12.10 and paragraph D of 12.05) exist as
a result of the individual’s mental disorder(s).
1. 12.02 Organic Mental Disorders
2. 12.03 Schizophrenic, Paranoid and Other Psychotic Disorders
3. 12.04 Affective Disorders
4. 12.05 Mental Retardation
5. 12.06 Anxiety-Related Disorders
6. 12.07 Somatoform Disorders
7. 12.08 Personality Disorders
8. 12.09 Substance Addiction Disorders
9. 12.10 Autism and Other Pervasive Developmental Disorders
2. DSM-IV Multiaxial Evaluation: Axis I: ___________________________________________
Axis II: ___________________________________________
Axis III: ___________________________________________
Axis IV: ___________________________________________
Axis V: ___________________________________________
Current GAF: Highest GAF Past
Year _____________
3. Treatment and response:_________________________________________________________________________
4. a. List of prescribed medications: _________________________________________________________________
_________________________________________________________________________________________ b.
Describe any side effects of medications that may have implications for working. E.g., dizziness, drowsiness, fatigue,
lethargy, stomach upset, etc.:_______________________________________________________________________
5. Describe the clinical findings including results of mental status examination that demonstrate the severity of your patient’s
mental impairment and symptoms: __________________________________________________________________
______________________________________________________________________________________________
6. Prognosis: _________________________________________________________________________________
7. Identify your patient’s signs and symptoms by checking to the left of the appropriate description:
Anhedonia or pervasive loss of interest in almost all Intense and unstable interpersonal relationships and impulsive and
activities damaging behavior
Recurrent and intrusive recollections of a traumatic Unrealistic interpretation of physical signs or sensations associated with
experience, which are a source of marked distress the preoccupation or belief that one has a serious disease or injury
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Psychomotor agitation or retardation Loosening of associations
Recurrent obsessions or compulsions which are a Memory impairment - short, intermediate or long term
source of marked distress
Psychological or behavioral abnormalities associated Recurrent sever panic attacks manifested by a sudden unpredictable
with a dysfunction of the brain with a specific organic onset of intense apprehension, fear, terror and sense of impending
factor judged to be etiologically related to the abnormal doom occurring on the average of at least once a week
mental state and loss of previously acquired functional
abilities
Bipolar syndrome with a history of episodic periods A history of multiple physical symptoms (for which there are organic
manifested by the full symptomatic picture of both findings) of several years duration beginning before age 30, that have
manic and depressive syndromes (and currently caused the individual to take medicine frequently, see a physician often
characterized by either or both syndromes) and alter life patterns significantly
Persistent irrational fear of a specific object, activity, or Involvement in activities that have a high probability of painful
situation which results in a compelling desire to avoid consequences which are not recognized
the dreaded object, activity or situation
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8. To determine your patient’s ability to do work-related activities on a day-to-day basis in a regular work setting, please give
us your opinion based on your examination of how your patient’s mental/emotional capabilities are affected by the
impairment(s). Consider the medical history, the chronicity of findings (or lack thereof), and the expected duration of any work-
related limitations, but not your patient’s age, sex or work experience.
Seriously limited, but not precluded means ability to function in this area is seriously limited and less than satisfactory, but not
precluded.
Unable to meet competitive standards means your patient cannot satisfactorily perform this activity independently,
appropriately, effectively and on a sustained basis in a regular work setting.
No useful ability to function, an extreme limitation, means your patient cannot perform this activity in a regular work setting.
I. MENTAL ABILITIES AND APTITUDES Unlimited or Limited but Seriously Unable to No useful
NEEDED TO DO UNSKILLED WORK Very Good satisfactory limited, but meet ability to
not competitive function
precluded standards
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Be aware of normal hazards and take
appropriate precautions
(Q) Explain limitations falling in the three most limited categories (identified by bold type) and include the medical/clinical
findings that support this assessment:
II. MENTAL ABILITIES AND APTITUDES Unlimited or Limited but Seriously Unable to No useful
NEEDED TO DO SEMI SKILLED AND Very Good satisfactory limited, but meet ability to
SKILLED WORK not precluded competitive function
standards
II. MENTAL ABILITIES AND APTITUDES Unlimited or Limited but Seriously Unable to No useful
NEEDED TO DO PARTICULAR TYPES Very Good satisfactory limited, but meet ability to
OF JOBS not precluded competitive function
standards
10. Does the psychiatric condition exacerbate Pt’s experience of pain or any other physical symptom? Yes No
If yes, please explain: __________________________________________________________________________
___________________________________________________________________________________________
B. Criteria of the Listings
Indicate to what degree the following functional limitations (which are found in paragraph B of listings 12.02-12.04, 12.06-12.08 and
12.10 and paragraph D of 12.05) exist as a result of the individual’s mental disorder(s).
FUNCTIONAL
LIMITATION DEGREE OF LIMITATION
1. Restriction of Activities None Mild Moderate
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Marked* Extreme* Insufficient
of Daily Living
Evidence
Evidence
Evidence
Extended Duration
C. 1. On the average, how often do you anticipate that your patient’s impairments or treatment would cause your patient to be
absent from work: (check appropriate box)
never about 1 day per month about 2
days per month about 3 days per month
about 4 days per month more than 4 days per month
2. Has your patient’s impairment lasted or can it be expected to last at least 12 months: yes no
If no, please explain:______________________________________________________________________________
3. Are your patent’s impairments reasonably consistent with the symptoms and functional limitations described in this
evaluation? yes
no
If no, please explain ______________________________________________________________________________
4. Please describe any additional reasons not covered above why your patient would have difficulty working at a regular
job on a sustained: ___________________________________________________________________________
5. Can your patient manage benefits in his or her own best interest? yes no
6. What is the earliest date that the description of symptoms and limitations in this form applies? ____________
_____________________________ _______________________
Physician’s Signature Date Form Completed
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Please Return Form To:
Mike Murburg P.A
15501 N. Florida Ave
Tampa, FL 33613
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