Residual Functional Capacity Ssa Listed Disorders Page 10

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How would you rate the patients’ creditability with regards to claims of pain?
Hearing or Vision Impairments
1. If a hearing impairment is present,
A. Does the individual retain the ability to hear and understand Simple oral instructions
and to communicate simple information? Yes ___ No ___
B. Can the individual use a telephone to communicate? Yes ___ No ___
2. If a visual impairment is present:
A. Is the individual able to avoid ordinary hazards in the workplace, such as boxes on the
floor, doors ajar, or approaching people or vehicles? Yes ___ No ___
B. Is the individual able to read very small print? Yes ___ No ___
C. Is the individual able to read ordinary newspaper or book print? Yes ___ No ___
D. Is the individual able to view a computer screen? Yes ___ No ___
E. Is the individual able to determine differences in shape and color of small objects such
as screws, nuts or bolts? Yes ___ No ___
Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings,
laboratory test results, history, and symptoms including pain etc.) which support your
assessment or any limitations and why the findings support the assessment.
Individual Activities
Can the individual perform activities like shopping? Yes ___ No ___
Can the individual travel without a companion for assistance? Yes ___ No ___
Can the individual ambulate without using a wheelchair, walker, or 2 canes or 2 crutches?
Yes ___ No ___
Can the individual walk a block at a reasonable pace on rough or uneven surfaces? Yes
___ No ___
Can the individual use standard public transportation? Yes ___ No ___
Can the individual climb a few steps at a reasonable pace with the use of a single hand
rail? Yes ___ No ___
Can the individual prepare a simple meal and feed himself/herself? Yes ___ No ___
Can the individual care for personal hygiene? Yes ___ No ___

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00 votes

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