Residual Functional Capacity Ssa Listed Disorders Page 11
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13Can the individual sort, handle, use paper and/or files? Yes ___ No ___
Please identify the medical findings that support this assessment and why the findings support
the assessment (unless a narrative report is attached).
Environmental Factors and Limitations
Condition
Never
Occasionally (up
Frequently (1/3 to
Continuously (over 2/3)
to 1/3)
213)
Unprotected
Heights
Moving
Mechanical Parts
Operating a
motor vehicle
Humidity and
wetness
Dust. odors,
fumes and
pulmonary
irritants
Extreme cold
Extreme heat
Vibrations
Other: (Identify)
Condition
Quiet
Moderate (Office)
Loud (Heavy Traffic) Very Loud (Jackhammer)
(Library)
Noise
Individual’s Ability to Travel
Would the patients disability or impairment prevent him or her from travelling alone?
Yes _____ No ______Why?
Individual’s Time Period of Restriction(s)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical