MEDICAL SOURCE STATEMENT
Physical residual functional capacity
Claimant name: Date of birth: SSN (last four):
Alleged onset date: Date of this statement:
Medical source completing this form
Name and credentials: Specialty:
License number and state: NPI:
Relationship to claimant: Treating since Examined once on Record review only
Records reviewed (attach a list if needed):
Instructions. Describe the most the claimant can do on a sustained basis in a work setting, eight hours a day, five days a week. For every limitation, state the clinical basis and the records that support it. Opinions on whether the claimant is disabled or can work are reserved to the Commissioner and should not be stated here.
1. Diagnoses that affect function, with the objective findings for each (imaging, labs, examination findings):
2. Lifting and carrying
Occasionally (up to one third of the day): less than 10 lb 10 lb 20 lb 50 lb more than 50 lb
Frequently (one third to two thirds of the day): less than 10 lb 10 lb 20 lb 25 lb more than 25 lb
Basis and records:
3. Standing and walking
Total in an 8-hour day: less than 2 hours about 2 hours about 4 hours about 6 hours
At one time without a break: minutes. Assistive device required: No Cane Walker Other
Basis and records:
4. Sitting
Total in an 8-hour day: less than 2 hours about 2 hours about 4 hours about 6 hours
At one time: minutes. Needs the option to alternate sitting and standing: No Yes, every minutes for minutes
Basis and records:
5. Postural activities (Never / Occasionally / Frequently)
Climb ramps and stairs Climb ladders, ropes, scaffolds Balance Stoop Kneel Crouch Crawl
Basis and records:
6. Manipulative activities, left and right (Never / Occasionally / Frequently / Unlimited)
Reach overhead L R Reach all other directions L R Handle (gross) L R Finger (fine) L R Feel L R
Basis and records:
7. Environmental restrictions (None / Avoid concentrated exposure / Avoid all exposure)
Unprotected heights Moving machinery Extreme cold Extreme heat Humidity Vibration Fumes, dusts, gases Noise
Basis and records:
8. Need to elevate legs during the workday: No Yes, to height, percent of the day. Basis:
9. Time off task because of symptoms, pain, or medication effects, in addition to normal breaks:
less than 5 percent 5 to 10 percent 10 to 15 percent 15 to 20 percent more than 20 percent
Basis and records:
10. Unscheduled absences from work because of impairments or treatment, per month:
none about 1 about 2 about 3 4 or more
Basis and records:
11. Earliest date the limitations above have applied at this level: Basis:
Expected to last 12 continuous months or longer: Yes No
12. Evidence in the record that conflicts with the limitations above, and how it was weighed:
Signature: Printed name: Date:
Fee for this statement, if any: $ Paid by: Claimant Representative No fee. Contingent on the outcome of the claim: No
Attach a narrative explaining the basis for each limitation with citations to the record. A form without explanation receives little weight.