Residual Functional Capacity Childhood Mental Disorders Page 8
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8Mild
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:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Please add any other comments which you feel will be helpful in assessing the child’s disability:
Date:
Signature Block
Mental Functional Assessment – Page Number 8
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