Rfc Forms For Disability Claims

[lmt033167]

I wasn't sure if there were RFC forms here or not, I can't find them and tried to point someone else to them, but feel free to use mine, you may have to adjust some margins etc, but I used these when I first filed my claim and had my dr sign them after reading them.

RFC - Residual Functional Capacity Form

About What the Claimant Can Still Do Despite Impairment(s)

Name ___________________________ Social Security No. _____________________

INSTRUCTIONS: Please complete the following assessment based on your clinical evaluation and test findings.

You are not required to perform any special test of functional capacity to render your opinions on this form.

1. Nature, frequency and length of contact: _______________________

2. Diagnoses: _________________________________________________

___________________________________________________________

3. Identify all of your patient?s symptoms, including pain , dizziness,

fatigue, etc.

____________________________________________________________

____________________________________________________________

4. If your patient has pain, characterize the nature, location, frequency, precipitating factors

and severity of your patient?s pain.

_____________________________________________________________

_____________________________________________________________

5. Identify any positive objective signs:

___ Reduced range of motion:

Joints affected: ________________________________________

____Joint warmth

____Joint deformity

____Joint instability

____Reduced grip strength

____ Sensory changes ____ Trigger points

____Reflex changes ____ Redness

____Impaired sleep ____ Swelling

____Weight change ____ Muscle spasm

____Impaired appetite ____ Muscle weakness

____Abnormal posture ____Muscle atrophy

____Tenderness ____Abnormal gait

____Crepitus ____Positive straight leg raising test

Other clinical findings: ____________________________________________________________________________

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

____Yes ____No

7. Identify any psychological conditions affecting pain:

____Depression ____Anxiety

____Somatoform disorder ____Personality disorder

____Psychological factors

affecting physical condition

Other: _____________________________________________________

8. How often is your patient?s experience of pain severe enough to interfere with attention and concentration?

___ Never ___ Seldom ___ Often ___ Frequently ___ Constantly

9. To what degree is your patient limited in the ability to deal with work stress?

___No limitation ___ Slight Limitation ___Moderate Limitation

___Marked Limitation ___ Severe Limitation

10. Identify the side effects of any medication which may have implications for working,

e.g., dizziness, drowsiness, stomach upset, etc. ______________

_______________________________________________________________

11. Please mark the activities the patient CAN perform on a regular and continuing basis. ?A regular and

continuing basis? means 8 hours a day for 5 days a week, or an equivalent work schedule.

SITTING in a working position at a desk or table without reclining.

A) MAXIMUM CONTINUOUSLY sitting before alternating postures standing or walking about.

(Circle one please)

<15 min 15 min 1 hr 2 hrs 3 hrs >3 hrs

After sitting for the maximum continuous period, does this patient need to ALTERNATE POSTURES by

standing or walking about? (Check 1 please)

___ YES, by walking about.

___ YES, but standing in place is sufficient

___ NO, alternating postures is not medically indicated.

C) If so, HOW LONG does the patient need to stand or walk about before returning to a seated position

for another maximum continuous interval? (Circle one please)

<15 min 15 min 30 min 1 hr 2 hrs 3 hrs >3 hrs

D) Is it medically necessary for this patient to elevate the legs while SITTING to minimize pain?

(check one please).

____ Yes, BOTH legs

____ Yes, RIGHT leg only

____ Yes, LEFT leg only

____ No, it is not necessary to elevate either leg while sitting.

E) If elevation of the patient?s legs is medically necessary, what DEGREE of elevation is appropriate?

____ Elevation to chest level or higher

____ Elevation to waist level

____ Elevation to only six inches or less

F) TOTAL CUMULATIVE sitting during an 8 hour work day, NOT INCLUDING time spent standing or walking about.

(Circle one please)

<1 hr 1 hr 2 hrs 3 hrs 4 hrs 5 hrs 6 hrs >6 hrs

12. STANDING AND WALKING ABOUT: weightbearing ambulating.

A) maximum continuously STANDING OR WALKING ABOUT before alternating postures sitting or lying down.

(Circle one please)

<15 min 15 min 30 min 1 hr 2 hrs 3 hrs >3 hrs

After standing or walking about for the maximum continuous period, does this patient need to ALTERNATE

POSTURES by sitting lying down or reclining in a supine positions?

____ YES, by lying down or reclining in a supine position.

____ YES, but sitting in a working position at a desk or table is sufficient.

____ NO, alternating postures is not medically indicated.

C) If so, HOW LONG does the patient need to sit or lie down/recline before returning to standing or

walking about for another maximum continuous interval? (Circle one please)

<15 min 15 min 30 min 1 hr 2 hrs 3 hrs >3 hrs

D) TOTAL CUMULATIVE standing or walking about during an

8-hour work day NOT INCLUDING time spent sitting or lying down/reclining. (Circle one please)

<1 hr 1 hr 2 hrs 3 hrs 4 hrs 5 hrs 6 hrs >6 hrs

13. RESTING lying down or reclining in a supine position in bed or in an easy chair.

A) Does this patient need to REST for some period of time during an 8 hour work day? (Circle one please)

_____ YES, in addition to a morning break, a lunch period,

and an afternoon break scheduled at approximately 2 hour intervals, more rest is needed.

_____ YES, but a morning break, a lunch period, and an afternoon break scheduled at approximately

2 hour intervals is sufficient.

_____ NO, rest lying down or in a supine position in bed or in an easy chair is not medically indicated.

If so, WHY does the patient need REST for some period of time during an 8 hour work day?

(Check one please)

_____ To relieve pain arising from a documented medical impairment

_____ To relieve fatigue arising from a documented medical impairment

_____ Non-Applicable. rest as defined is not medically indicated.

C) If so, what is the TOTAL CUMULATIVE resting/lying down or reclining in a supine position needed during

an 8 hours work day?

<1 hr 1 hr 2 hrs 3 hrs 4 hrs 5 hrs 6 hrs >6 Hrs

14. LIFTING AND CARRYING (Check one at each weight level)

Weight in Pounds Never Occasionally Frequently Constantly

(no sustained/8hrs) (up to 1/3 of day) (1/3-2/3 of day) (>2/3 of day)

1-5 lbs. _______________ ________________ _______________ _____________

6-10 lbs. _______________ ________________ _______________ _____________

11-20 lbs. _______________ ________________ _______________ _____________

21-50 lbs. _______________ ________________ _______________ _____________

15. BALANCING when standing/walking

on level terrain _______________ ________________ _______________ _____________

(check one)

16. STOOPING bending the body

downward and forward by bending

the spine at the waist

(check one) _______________ ________________ _______________ _____________

17. POSTURES of Neck:

A) Forward Flexion _______________ ________________ _______________ _____________

(i.e. Looking down at a

table or desk)

Backward Flexion_______________ ________________ _______________ _____________

(i.e. Looking upward to ceiling/sky)

C) Rotation Right _______________ ________________ _______________ _____________

(i.e. Looking sideways to right)

D) Rotation Left _______________ ________________ _______________ _____________

(i.e. Looking sideways to left)

REPETITIVE USE OF HANDS

A) Reaching (i.e. extending the hands and arms in any direction)

Never Occasionally Frequently Constantly

RIGHT HAND _______________ ________________ _______________ _____________

LEFT HAND _______________ ________________ _______________ _____________

Handling (i.e. seizing, grasping, turning or otherwise working primarily with the whole hand)

RIGHT HAND _______________ ________________ _______________ _____________

LEFT HAND _______________ ________________ _______________ _____________

C) Fingering (i.e. picking, pinching or otherwise working primarily with the fingers)

RIGHT HAND _______________ ________________ _______________ _____________

LEFT HAND _______________ ________________ _______________ _____________

18. ASSISTIVE DEVICES FOR AMBULATING

A) Is a hand held assistive device medically required to aid the patient in walking or standing?

____ YES, to aid in BOTH walking and standing

____ YES, to aid in ONLY walking, not standing

____ NO

If so, what TYPE of hand-held assistive device is medically required?

___ CANE

___ WALKER

___ 2 CRUTCHES

___ 1 CRUTCH

C) If so, in what CIRCUMSTANCES is the hand-held assistive device medically required?

___ On ALL surfaces and terrains for all ambulation

___ ONLY on uneven surfaces and terrains or slopes

___ ONLY for prolonged ambulation

19. Are your patient?s impairments likely to produce ?good days? and ?bad days??

If yes, please estimate, on the average, how often your patient is likely to be absent from work as a

result of the impairments or treatment:

___ Never ___ About twice a month

___ Less than once a month ___ About 3 times a month

___ About once a month ___ More than 3 times a month

20. PERIOD OF RESTRICTION:

Has the patient?s condition existed and persisted with the restrictions as outlined in this Medical Source

Statement at least since ______________________?

___ Yes

___ No

If not, state the first date the patient?s condition existed and persisted with such restrictions:

______________________?

CERTIFICATION

By my signature appended hereto, I attest that I personally have answered each of the questions presented in this

Medical Source Statement assessment form and I believe the information contained herein to be true and accurate to

the best of my knowledge and professional judgment.

Dated _____________________

________________________________

Physician?s Signature

________________________________

Physician?s Name Printed

________________________________

Physician?s Address

RFC Mental

About What the Claimant Can Still Do Despite Mental Impairment(s)

Name: __________________________ Social Security No. ________________________

Please answer the following questions concerning your patient?s impairments.

1. Frequency and length of contact: ______________________________________________________

________________________________________________________________________________

___________

2. DSM-IV Multitaxial Evaluation:

Axis I _____________________________ Axis IV: _____________________________________

Axis II ____________________________ Axis V: Current GAF: _________________________

Axis III ___________________________ Highest GAF past year: ________________________

3. Identify your patient?s signs and symptoms:

a. Poor memory ______

b. Appetite disturbance with weight change ______

c. Sleep disturbance ______

d. Personality change ______

e. Mood disturbance ______

f. Emotional lability ______

g. Loss of intellectual ability of 15 IQ points or more ______

h. Delusions or hallucinations ______

i. Substance dependence ______

j. Recurrent panic attacks ______

k. Anhedonia or pervasive loss of interests ______

l. Psychomotor agitation or retardation ______

m. Paranoia or inappropriate suspiciousness ______

n. Feelings of guilt/worthlessness ______

o. Difficulty thinking or concentrating ______

p. Suicidal ideation or attempts ______

q. Oddities of thought, perception, speech or behavior ______

r. Perceptual disturbances ______

s. Time or place disorientation ______

t. Catatonia or grossly disorganized behavior ______

u. Social withdrawal or isolation ______

v. Blunt, flat or inappropriate affect ______

w. Illogical thinking or loosening of associations ______

x. Decreased energy ______

y. Manic syndrome ______

z. Obsessions or compulsions ______

aa. Intrusive recollections of a traumatic experience ______

bb. Persistent irrational fears ______

cc. Generalized persistent anxiety ______

dd. Somatization unexplained by organic disturbance ______

ee. Hostility and irritability ______

ff. Pathological dependence or passivity ______

Other symptoms and remarks: _______________________________________________________

________________________________________________________________________________

___

4. Describe the clinical findings including results of mental status examination which demonstrate the

severity of your patient?s mental impairment and symptoms:

________________________________________________________________________________

_______

________________________________________________________________________________

_______

________________________________________________________________________________

_______

5. Are your patient?s impairments reasonably consistent with the symptoms and functional limitations

described in this evaluation? ______ Yes ______ No

If no, please explain: ____________________________________________________________________

________________________________________________________________________________

_______

6. a. List prescribed medication and dosage Daily Amount Taken

__________________________________ ___________________________

__________________________________ ___________________________

__________________________________ ____________________________

__________________________________ ____________________________

b. Describe any side effects of medications which may have implications for working, e.g.

dizziness, drowsiness, fatigue, lethargy, stomach upset, etc: __________________________________

________________________________________________________________________________

_______

________________________________________________________________________________

_______

7. Does your patient have a low I.Q. or reduced intellectual functioning?

______ Yes ______ No

Please explain (with reference to specific test results): ________________________________________

________________________________________________________________________________

_______

________________________________________________________________________________

_______

8. On the average, how often do you anticipate that your patient?s impairments or treatment would cause

your patient to be absent from work?

___Never ___ Less than once a month ___ About once a month

___ About twice a month ___ About three times a month ___ More than 3 times a month

Independent of any impairment from alcoholism and/or drug addiction, please rate the

individual?s capabilities to perform the following basic mental activities of work on a

regular and continuing basis.

?Regular and continuing basis? means 8 hours a day for 5 days a week or an equivalent work schedule.

No/mild loss No significant loss of ability in the named activity; can sustain

performance for 2/3 or more of an 8-hour workday.

Moderate loss Some loss of ability in the named activity but still can sustain

performance for 1/3 up to 2/3 of an 8-hour workday.

Marked loss substantial loss of ability in the named activity; can sustain

performance only up to 1/3 of an 8-hour workday.

Extreme loss Complete loss of ability in the named activity; can not sustain

performance during an 8-hour workday.

9. Is ability to understand, remember and carry out instructions affected by the impairment?

_____Yes _____No

If ?no?, go to next question. If ?yes?, please check the appropriate block to described the

individual?s ability to perform the following work-related mental activities:

No/mild Moderate Marked Extreme

Loss Loss Loss Loss

a. Remember locations and work-like procedures _______ _______ _______ ______

b. Understand and remember very short,

simple instructions. _______ ________ _______ _______

c. Carry out very short, simple instructions ______ ________ _______ _______

d. Understand and remember detailed instructions ______ ________ ________ ________

e. Carry out detailed instructions _______ ________ ________ _________

f. Maintain attention and concentration

for extended periods, i.e. 2 hour segments _______ ________ ________ ________

g. Maintain regular attendance and be punctual _______ ________ ________ ________

h. Sustain an ordinary routine without special

supervision. _______ ________ ________ ________

i. Deal with stress of semi-skilled and

skilled work _______ ________ ________ ________

j. Work in coordination with or proximity

to others without being unduly distracted _______ ________ ________ ________

k. Make simple work-related decisions. _______ ________ ________ ________

l. Complete a normal workday or workweek

without interruptions from psychologically

based symptoms _______ ________ ________ ________

m. Perform at a consistent pace without an

unreasonable number and length of rest periods _______ ________ ________ ________

10. Is ability to respond appropriately to supervision, coworkers and work pressure in a work-setting

affected by the impairment? If ?no?, go to next question. If ?yes?, please check the appropriate block to

describe the individual?s ability to perform the following work-related mental activities.

______ Yes ______ No

No/Mild Moderate Marked Extreme

Loss Loss Loss Loss

a. Interact appropriately with the public _______ ________ ________ ________

b. Ask simple questions or request assistance. _______ ________ ________ ________

c. Accept instructions and respond appropriately

to criticism from supervisors. _______ ________ ________ ________

d. Get along with coworkers and peers

without unduly distracting them or exhibiting

behavioral extremes. _______ ________ ________ ________

e. Maintain socially appropriate behavior _______ ________ ________ ________

f. Adhere to basic standards of neatness and

cleanliness. _______ ________ ________ ________

g. Respond appropriately to changes in a

routine work setting _______ ________ ________ ________

h. Be aware of normal hazards and take

appropriate precautions _______ ________ ________ ________

i. Travel in unfamiliar places _______ ________ ________ ________

j. Use public transportation _______ ________ ________ ________

k. Set realistic goals or make plans

independently of others _______ ________ ________ ________

11. Indicate to what degree the following functional limitations exist as a result of your patient?s mental impairments.

FUNCTIONAL LIMITATION DEGREE OF LIMITATION

a. Restriction of activities of daily living: None _ Slight __ Moderate __Marked * __ Extreme __

b. Difficulties in maintaining social

functioning: None __ Slight __ Moderate __ Marked ___ Extreme ___

c. Deficiencies of concentration,

persistent or pace resulting in

failure to complete tasks in a

timely manner (in work settings

or elsewhere) Never __ Seldom __ Often __ Frequent ___ Constant ___

d. Episodes of deterioration or

decompensation in work or work-

like settings which cause the

individual to withdraw from that

situation or to experience exacerbation

of signs and symptoms (which may

include deterioration of adaptive

behaviors) Never ___ Once or Twice ___ Repeated ___ Continual ___

*Note: Marked means more than moderate, but less than extreme. A marked limitation may arise when several activities or

functions are impaired or even when only one is impaired, so long as the degree of limitation is such as to seriously

interfere with the ability to function independently, appropriately and effectively.

12 . Can your patient manage benefits in his or her own best interest? ____ Yes _____ No

13. PERIOD OF RESTRICTION: Has the individual?s condition existed and persisted with the restrictions as outlined in

this Medical Source Statement at least since ______________?

____ Yes ____ No

If not, state the first date the patient?s condition existed and persisted with such restrictions.

______________________________

CERTIFICATION

By my signature appended hereto, I attest that I have answered truthfully and accurately to the best of my ability,

each of the questions presented in this Medical Source Statement rating the individual?s capabilities independent of any

impairment from alcoholism and/or drug addiction.

Dated _____________________________

______________________________

Signature

______________________________

Printed Name

______________________________

Address

[Simmy]

Hi Lisa,

Yes, that's the form you pointed me to last week. Thank you, and thanks for posting this for others.

I found a similar one online and had my doctor fill it out right away. He had to cross some things out and fill in by hand, like, "After sitting for the maximum continuous period, does this patient need to ALTERNATE POSTURES by standing or walking about?" he added "BY LYING DOWN."

I'm not sure social security will appreciate the smileys though

[lmt033167]

Hi Lisa,

Yes, that's the form you pointed me to last week. Thank you, and thanks for posting this for others.

I found a similar one online and had my doctor fill it out right away. He had to cross some things out and fill in by hand, like, "After sitting for the maximum continuous period, does this patient need to ALTERNATE POSTURES by standing or walking about?" he added "BY LYING DOWN."

I'm not sure social security will appreciate the smileys though

lol no clue how they got in there, going to try and fix it now

[Rachel]

Hi Lisa,

I'm not sure social security will appreciate the smileys though

lol no clue how they got in there, going to try and fix it now

The smiley faces with the sunglasses are in the form because the code for that smiley is a "B" immediately followed by ")". If you put a space between the two then it will look similar to the A), C), etc.

Here's what I'm talking about:

A)

C)

A)

B )

C)

I hope that all made sense!

Rachel

[erik]

Unchecking the "[ ] Enable emoticons?" checkbox should prevent the D) and such from being turned into an image. If you do a "full edit" on the first post it should re-offer that option.

[tinkerbella]

LOL,LOL,LOL, LEAVE THEM YOU MIGHT JUST make someone's day! and get a free pass in......

[lmt033167]

LOL,LOL,LOL, LEAVE THEM YOU MIGHT JUST make someone's day! and get a free pass in......

lol good idea, I need all the help I can get