Residual Functional Capacity Childhood Mental Disorders Page 7
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8with others to meet one’s needs. It also incorporates the concept that the child should be
developing an increasing sense of independence and competence.
Level of Impairment:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Health and physical well-being. What are the cumulative physical effects of physical and/or
mental impairments. Considered are the effects of chronic illness, including shortness of breath,
reduced stamina, pain and poor growth. Also includes are the impact of therapies, medications
and periods of exacerbation and remission.
Level 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:
Mental Functional Assessment – Page Number 7
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