Residual Functional Capacity Childhood Mental Disorders Page 6
ADVERTISEMENT
1
2
3
4
5
6
7Level of Impairment:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
MEDICATIONS
List Prescribed Medications and identify condition for which medications are prescribed.
Is there a reasonable medical probability your patient will experience side effects from the
medication(s) listed above?
Yes
No
Other:
To what degree will the side effects of the prescribed medications impair your patient’s ability
for concentration, persistence and pace in combination with the underlying condition(s)?
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
When side effects exist can you estimate the severity?
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Is your patient allowed to operate machinery or motorized vehicles when experiencing side
effects from the medication – if over 16 years of age?
Yes
No
Is there a reasonable medical probability that the side effects will reduce your patient’s ability to
perform work to a minimum standard of productivity? If yes, to what degree:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Is there a reasonable medical probability that the side effects will reduce your patient’s ability to
perform detailed work requiring hand/eye coordination? If yes, to what degree:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Is there a reasonable medical probability that the side effects will reduce your patient’s cognitive
acuity and/or ability to focus on activities such as reading, writing, computer use? If yes, to what
degree:
Mental Functional Assessment – Page Number 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical