Examining Physician'S Statement For Application For Disability Benefits Form Page 2


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Name of Claimant
Social Security Number
This page must be completed in its ENTIRETY and returned to PERA for processing. Do not use “See Attached”.
11. A brief explanation of treatment plan and medications ________________________________________________
12. Describe the claimant’s functional limitations (i.e. mobility, dexterity, attitude, etc as to employment and/or activities
or daily living.)_______________________________________________________________________________
13. Please attach any applicable reports referenced in #12 above. (i.e. functional capacity evaluation, PT notes, etc.)
14. A brief explanation of expected duration of restrictions ________________________________________________
15. Type of work claimant is presently capable of performing
No Work.
Sedentary Work. May include lifting 10lbs. And occasionally lifting
or carrying such articles as dockets, ledgers and small tools. Job is primarily done sitting, and only
occasional walking and standing are required.
Light work. May include lifting 20lbs. maximum, with frequent lifting
and/or carrying objects weighing up to 10lbs. Job requires walking
or standing to a significant degree, or involves sitting most of the
time with a degree of pushing or pulling of arm and leg controls.
Medium work. May include lifting 50lbs. maximum with frequent
lifting and/or carrying objects weighing up to 25 lbs.
Heavy work. May include lifting 100lbs. maximum with frequent
lifting and/or carrying objects weighing up to 50 lbs.
Very heavy work. Lifting object in excess of 100lbs. with frequent
lifting and/or carrying objects weighing 50 lbs. or more.
Other (Describe)
16. Has the claimant reached maximum medical improvement?
When do you estimate the claimant will
reach maximum medical improvement?
17. If claimant is not presently capable of performing any gainful employment, will claimant be able to
return to some type of employment? Yes
If yes, approximate date
September 2015
Page 2 Examining Physician’s Statement


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