Disability Claim Form - Principal Financial Group Page 4
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MENTAL IMPAIRMENT (if applicable) Provide 5 AXIS Diagnosis
I
IV
II
V
III
Please define “stress” as it applies to your patient:
Could your patient perform his/her job if it was for a different employer/supervisor?
yes
no
19
CARDIAC (if applicable)
If this is a cardiac condition, what is the functional capacity? (American Heart Association)
C1
C2
C3
C4
20
PHYSICAL IMPAIRMENT
Have you advised your patient to restrict employment activities?
yes
no
If yes, beginning on what date?
Please provide the specific restrictions and limitations YOU have placed on your patient in the space provided below:
CONTINUOUSLY
FREQUENTLY
OCCASIONALLY
NEVER
(2/3 + of time)
(1/3 – 2/3 of time)
(Up to 1/3 of time)
Sit
Stand
Walk
Lift/Carry
lbs.
lbs.
lbs.
lbs.
Power Grasp
Fine Manipulation
Push/Pull
Keyboarding
Reach above shoulder level
Reach at waist level/below waist
Bend/Twist/Squat
Climb/Balance
Please provide any additional restrictions and limitations not specified above, including other factors that may affect employment activities:
PROGNOSIS:
Have you discussed your patient’s job duties?
yes
no
Has your patient been released to return to work?
yes
no
If yes, please provide date
If the employer can accommodate the patient’s limitations, do you support return to work at this time?
yes
no
If the employer can accommodate part-time work, do you support return to work at this time?
yes
no
If yes, how many hours per day?
If your patient has not been released to return to work, please provide an estimated return to work/recovery date.
Please explain if this date falls beyond the typical recovery time for this diagnosis.
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Physician Name (Please Print)
Degree
Specialty
Phone Number
FAX Number
Address
City
State
Zip Code
Please provide a contact name for additional questions.
Signature (No Stamp)
Tax ID Number
Date
X
GP60515-01
Page 4 of 7
05/2013
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