Residual Functional Capacity Ssa Listed Disorders
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13THESE ARE THE FORMS I USE – THIS IS NOT LEGAL ADVICE AND INTENDED TO
SUPPLEMENT YOUR PARTICULAR FACTUAL SITUATION ONLY – It is crucial you
educate yourself on the Social Security Regulations that define and govern impairments prior to
preparing this form for review. Absolutely, this form should be modified to address the specific
impairment as identified in the SSA Listings of Impairments of Adults.
Lee Ann Torrans
Residual Functional Capacity
SSA Listed Disorders
Name:
SSN:
DOB:
Health Care Provider Name:
Health Care Provider Relationship to Patient:
When First Treated Patient:
How Often Sees Patient:
Primary Diagnosis:
Date of Onset:
Secondary Diagnosis:
Date of Onset:
Other Impairments:
Date of Onset:
INSTRUCTIONS: Please complete the following assessment based on your clinical evaluation
and test findings. You are not required to perform any special test of functional capacity to
render your opinions on this form. To determine this individual's ability to do work-related
activities on a regular and continuous basis, please give us your opinions for each activity shown
below.
The following terms are defined as:
REGULAR AND CONTINUOUS BASIS means 8 hours a day, for 5 days a week, or an
equivalent work schedule.
OCCASIONALLY means very little to one-third of the time.
FREQIENTLY means from one-third to two-thirds of the time.
CONTINUOUSLY or CONSTANTLY means more than two-thirds of the time.
Age and body habitus of the individual should not be considered in the assessment of limitations.
It is important that you relate particular medical or clinical findings to any assessed limitations in
capacity: The usefulness of your assessment depends on the extent to which you do this.
Nature, frequency and length of contact:
Diagnoses:
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