Residual Functional Capacity Ssa Listed Disorders Page 12
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13Has the patient’s condition existed and persisted with the restrictions as outlined in this Medical
Source Statement at least since ______________________?
___ Yes ___ No
If not, state the first date the patient’s condition existed and persisted with such restrictions:
______________________?
How would you expect the claimant’s diagnosis/disability to change over time?
____ Disability is Not Likely to Change
____Disability is Temporary: From: _________To: ____________
When would you expect the claimant to return to work, with and/or without any restrictions?
Please
Are there any other factors not addressed in the above questions that you believe may affect the
patients’ ability to work, or function normally in daily life including at work and at home?
STATE ANY OTHER WORK-RELATED ACTIVITIES, WHICH ARE AFFECTED BY ANY
IMPAIRMENTS, AND INDICATE HOW THE ACTNITIES ARE AFFECTED. WHAT ARE
THE MEDICAL FINDINGS -THAT SUPPORTS THIS ASSESSMENT?
THE LIMITATIONS ABOVE ARE ASSUMED TO BE YOUR OPINION REGARDING
CURRENT LIMITATIONS ONLY. HOWEVER, IF YOU HAVE SUFFICIENT
INFORMATION TO FORM AN OPINION WITHIN A REASONABLE DEGREE OF
MEDICAL PROBABILITY AS TO PAST LIMITATIONS, ON WHAT DATE WERE THE
LIMITATIONS YOU FOUND ABOVE FIRST PRESENT?
HAVE THE LIMITATIONS YOU FOUND ABOVE LASTED OR WILL THEY LAST FOR
12 CONSECUTIVE MONTHS? ___ Yes ___ No
CERTIFICATION
By my signature appended hereto, I attest that I personally have answered
each of the questions presented in this Medical Source Statement assessment
form and I believe the information contained herein to be true and accurate
to the best of my knowledge and professional judgment.
Dated:
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