ࡱ>  Pbbjbj]q]q ^??Z2DKI342222222Q5722322VZ$@%Tvt$ % 30I3$x88%%% M:   PHYSICAL & MENTAL COMBINED RESIDUAL FUNCTIONAL CAPACITY REPORT TO: Social Security Administration RE: _______________________ 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. 1. Frequency and length of contact: _________________________________________________ 2. Diagnoses: ____________________________________________________________________ 3. Prognosis: ____________________________________________________________________ 4. List your patients symptoms, including pain, dizziness, fatigue, etc.: _______________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. Identify the clinical findings and objective signs: ________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6. If your patient has pain, characterize the nature, location, frequency, precipitating factors, and severity, of your patients pain:_____________________________________________________ ______________________________________________________________________________ 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. Have your patients impairments lasted or can they be expected to last 12 months? ( yes ( no 9. Is your patient a malingerer? ( yes ( no 10. Do emotional factors contribute to the severity of your patient(s symptoms and functional limitations? ( yes ( no 11. Identify any psychological conditions affecting your patients physical condition: ( Anxiety ( Somatoform disorder ( Personality Disorder ( Depression ( Psychological factors affecting physical condition ( Other: 12. Are your patients 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 patients impairments, estimate your patients 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 ( 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 patients 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 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 ( ( ( ( d. How often can your patient perform the following activities? Never Rarely Occasionally Frequently Twist ( ( ( ( Stoop (bend) ( ( ( ( Crouch/squat ( ( ( ( Climb ladders ( ( ( ( Climb stairs ( ( ( ( Kneel ( ( ( ( Crawl ( ( ( ( Balance ( ( ( ( e. Does the patient have significant limitations with reaching, handling or fingering? (Yes (No f. How often can the individual perform the following Physical Functions? Never Rarely Occasionally Frequently Reaching ( ( ( ( Handling ( ( ( ( Feeling ( ( ( ( Pushing/Pulling ( ( ( ( Hearing ( ( ( ( Speaking ( ( ( ( Are your patients 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 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 Restriction Yes No  Restriction Yes No Heights    Chemicals   Moving Machinery    Wetness   Vibrations    Dryness   Noise     Temperature Extremes   Solvent/Cleaners    High Humidity   Dust, fumes, odors smoke    Soldering Fluxes   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 patients ability to work at a regular job on a sustained basis: _________________________________________________________________________________________________________________________________________________________ 17. Based on the Claimants medical history and/or clinical presentation what is the earliest date that the description of symptoms and limitations in this questionnaire applies? _____________________ *************************************************************************************** MENTAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE AND LISTINGS Please answer the following questions concerning your patients impairments. Attach all relevant treatment notes and test results that have not been provided previously to the Social Security Administration. 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 individuals 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 patients mental impairment and symptoms: __________________________________________________________________ ______________________________________________________________________________________________ 6. Prognosis: _________________________________________________________________________________ 7. Identify your patients signs and symptoms by checking to the left of the appropriate description:  Anhedonia or pervasive loss of interest in almost all activities  Intense and unstable interpersonal relationships and impulsive and damaging behavior  Appetite disturbance with weight change  Disorientation to time and place  Decreased energy  Perceptual or thinking disturbances  Thoughts of suicide  Hallucinations or delusions  Blunt, flat or inappropriate affect  Hyperactivity  Feelings of guilt or worthlessness  Motor tension  Impairment in impulse control  Catatonic or other grossly disorganized behavior  Poverty of content of speech  Emotional liability  Generalized persistent anxiety  Flight of ideas  Somatization unexplained by organic disturbance  Manic syndrome  Mood disturbance  Deeply ingrained, maladaptive patterns of behavior  Difficulty thinking or concentrating  Inflated self-esteem  Recurrent and intrusive recollections of a traumatic experience, which are a source of marked distress  Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury  Psychomotor agitation or retardation  Loosening of associations  Pathological dependence, passivity or agressivity  Illogical thinking  Persistent nonorganic disturbance of vision, speech, hearing, use of a limb, movement and its control, or sensation  Pathologically inappropriate suspiciousness or hostility  Change in personality  Pressures of speech   Apprehensive expectation  Easy distractibility  Paranoid thinking or inappropriate suspiciousness  Autonomic hyperactivity  Recurrent obsessions or compulsions which are a source of marked distress  Memory impairment - short, intermediate or long term  Seclusiveness or autistic thinking  sleep disturbance  Substance dependence  Oddities of thought, perception, speech or behavior  Incoherence  Decreased need for sleep  Emotional withdrawal or isolation  Loss of intellectual ability of 15 IQ points or more  Psychological or behavioral abnormalities associated with a dysfunction of the brain with a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities  Recurrent sever panic attacks manifested by a sudden unpredictable onset of intense apprehension, fear, terror and sense of impending doom occurring on the average of at least once a week  Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both manic and depressive syndromes (and currently characterized by either or both syndromes)  A history of multiple physical symptoms (for which there are organic findings) of several years duration beginning before age 30, that have caused the individual to take medicine frequently, see a physician often and alter life patterns significantly  Persistent irrational fear of a specific object, activity, or situation which results in a compelling desire to avoid the dreaded object, activity or situation  Involvement in activities that have a high probability of painful consequences which are not recognized 8. To determine your patients 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 patients 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 patients 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 NEEDED TO DO UNSKILLED WORK Unlimited or Very Good Limited but satisfactory Seriously limited, but not precluded Unable to meet competitive standards No useful ability to function Remember work-like procedures      Understand and remember very short and simple instructions      Carry out very short and simple instructions      Maintain attention for two hour segment      Maintain regular attendance and be punctual within customary, usually strict tolerances      Sustain an ordinary routine without special supervision      Work in coordination with a proximity to others without being unduly distracted      Make simple work-related decisions       Complete a normal workday and workweek without interruptions from psychologically based symptoms      Perform at a consistent pace without an unreasonable number and length of rest periods      Ask a simple questions or request assistance      Accept instructions and respond appropriately to criticism from supervisors      Get along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes      Respond appropriately to changes in a routine work setting      Deal with normal work stress      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 NEEDED TO DO SEMI SKILLED AND SKILLED WORK Unlimited or Very Good Limited but satisfactory Seriously limited, but not precluded Unable to meet competitive standards No useful ability to function Understand and remember detailed instructions      Carry out detailed instructions      Set realistic goals or make plans independently of others      Deal with stress of semi skilled and skilled work     (E) 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 NEEDED TO DO PARTICULAR TYPES OF JOBS Unlimited or Very Good Limited but satisfactory Seriously limited, but not precluded Unable to meet competitive standards No useful ability to function Interact appropriately with the general public      Maintain socially appropriate behavior      Adhere to basic standards of neatness and cleanliness       Use public transportation      Travel to unfamiliar place      (F) Explain limitations falling in the three most limited categories (identified by bold type) and include the medical/clinical findings that support this assessment: 9. Does your patient have a low IQ or reduced intellectual functioning? Yes No Please explain (with reference to specific test results): ____________________________________________________ _______________________________________________________________________________________________ 10. Does the psychiatric condition exacerbate Pts experience of pain or any other physical symptom? Yes No If yes, please explain: __________________________________________________________________________ ___________________________________________________________________________________________ Criteria of the Listings SEQ CHAPTER \h \r 1 Indicate to what degree the following functional limitations (which are found in paragraphB of listings12.02-12.04, 12.06-12.08 and 12.10 and paragraph D of 12.05) exist as a result of the individuals mental disorder(s). FUNCTIONAL LIMITATION DEGREE OF LIMITATION 1. Restriction of Activities None Mild Moderate Marked* Extreme* Insufficient of Daily Living Evidence 2. Difficulties in Maintaining None Mild Moderate Marked* Extreme* Insufficient Social Functioning Evidence 3. Difficulties in Maintaining None Mild Moderate Marked* Extreme* Insufficient Concentration, Evidence 4. Repeated Episodes of None One or Two Three or Four More* Insufficient Decompensation, each of Evidence Extended Duration C. 1. On the average, how often do you anticipate that your patients 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 patients impairment lasted or can it be expected to last at least 12 months: ( yes ( no If no, please explain:______________________________________________________________________________ 3. Are your patents 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? ____________ _____________________________ _______________________ Physicians Signature Date Form Completed Printed/Typed Name: ___________________________________ __________________________________ __________________________________ Please Return Form To: Mike Murburg P.A 15501 N. Florida Ave Tampa, FL 33613     PAGE  PAGE 3 PAGE 6 >?@Envwx  ŶťŶseTeCeC hV6CJOJQJ]^JaJ j=hVCJOJQJ^JaJhVCJOJQJ^JaJ hR hVCJOJQJ^JaJ#h$hV>*CJOJQJ^JaJhV5CJOJQJ^JaJ hFhVCJOJQJ^JaJhV>*CJOJQJ^JaJhVCJOJQJ^JaJhRFhVOJQJ^JaJhV>*OJQJ^JaJhRFhV>*OJQJ^JaJ?@ M  T  ~ ! 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