1. How often have you seen the patient? What was the first date seen?
2. What are the patient's diagnoses?
3. What is the patient's prognosis?
4. What are the clinical findings, laboratory and test results that show your patient's medical impairments?
5. Is your patient a malingerer?
6. What are your patient's symptoms?
7. If your patient has pain, characterize the nature, location, radiation, frequency, precipitating factors, and severity of your patient's pain.
8. Do emotional factors contribute to the severity of your patient's symptoms and functional limitations?
9. Are your patient’s impairments (physical impairments plus any emotional impairments) reasonably consistent with the symptoms and functional limitations described in this evaluation?
10. 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 work tasks?
__ Never __ Rarely __ Occasionally __ Frequently __Constantly
For this and other questions on 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.
11. Identify the side effects of any medication that may have implications for working, e.g., dizziness, drowsiness, stomach upset, etc.
12. Have your patient's impairments lasted or can they be expected to last at least twelve months?
13. As a result of your patient's impairments, estimate your patient's functional limitations if your patient were placed in a competitive work situation:
a. How many city blocks can your patient walk without rest or severe pain?
b. How many hours and/or minutes can your patient sit at one time, e.g., before needing to get up, etc.?
c. How many hours and/or minutes can your patient stand at one time, e.g., before needing to get up, etc.?
d. Please indicate how long your patient can sit and stand/walk total in an 8- hour working day (with normal breaks):
__ __ less than 2 hours
__ __ about 2 hours
__ __ about 4 hours
__ __ at least 6 hours
e. Does your patient need to include periods of walking around during an 8-hour working day?
1. If yes, approximately how often must your patient walk?
2. How long must your patient walk each time?
f. Does your patient need a job that permits shifting positions at will from sitting, standing or walking?
g. Will your patient sometimes need to take unscheduled breaks during an 8-hour working day?
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?
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?
j. 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. __ __ __ __
k. How often can your patient perform the following activities?
Never Rarely Occasionally Frequently
Twist __ __ __ __
Stoop (bend) __ __ __ __
Crouch/ squat __ __ __ __
Climb ladders __ __ __ __
Climb stairs __ __ __ __
l. Does your patient have significant limitations with reaching, handling or fingering?
If yes, please indicate the percentage of time during an 8-hour working day that your patient can use hands/fingers/arms.
m. Are your patient’s impairments likely to produce “good days” and “bad days”?
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
If there are certain symptoms that can be expected with your specific disease, you can add questions about that. For example, if you have Lupus and one of your symptoms is a butterfly rash on your face, you can add that to the questionnaire. If you are working with an attorney, your attorney can develope a questionnaire tailored to your disability.
REMEMBER: Simply stating that you have a disease does not necessarily indicate that you are disabled. A questionnaire like this will help your insurance company and/or the Social Security Administration determine your individual restrictions and limitations.
Copyright (c) 2008 by John V. Tucker and Tucker & Ludin, P.A. All rights reserved. For assistance with your Long Term Disability claim, ERISA Disability benefit claim, Social Security Disability claim, or Veterans Disability compensation or pension claim, call Disability Lawyer John Tucker at (866) 282-5260.