Residual Functional Capacity Form for PHYSICAL IMPAIRMENTS
(RFC Form) For Physician to Complete
MEDICAL SOURCE STATEMENT
https://secure.ssa.gov/apps10/poms/images/SSA4/G-SSA-4734-U8-1.pdf
LET ME SAY IF YOU ATTORNEY HAS NOT DRAWN UP AN RFC FORM FOR YOUR TREATING PHYSICIAN SPECIALLY TAILORED TO YOUR PHYSICAL ISSUES WITHIN TWO MONTHS OF YOUR HEARING THEN YOUR ATTORNEY HAS NOT DONE THEIR JOB.
DO NOT GO TO A HEARING WITHOUT A RECENT RFC FORM THAT ADDRESSES YOUR ISSUES – WHETHER YOU ARE REPRESENTING YOURSELF OR YOU HAVE AN ATTY.
IF YOU HAVE AN ATTY YOU SHOULD HAVE AN RFC FORM SPECIALLY DRAFTED TO ADDRESS YOUR PHYSICAL LIMITATIONS AS THEY PERTAIN TO YOUR ABILITY TO WORK.
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
B) 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
B) 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.
B) 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)
B) 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 _______________ ________________ _______________ _____________
B) 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
B) 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