Residual Functional Capacity Ssa Listed Disorders Page 2
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13Identify 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.
Identify all of your patient’s symptoms, including pain, dizziness, fatigue, etc.
If your patient has pain, characterize the nature, location, frequency, precipitating factors and
severity of your patient’s pain.
Identify any positive objective signs:
___ Reduced range of motion:
Joints affected: ________________________________________
____Joint warmth ____Joint deformity ____Joint instability ____Reduced grip strength
____ Sensory changes ____ Trigger points ____Reflex changes ____ Redness
____Impaired sleep ____ Swelling ____Weight change ____ Muscle spasm
____Impaired appetite ____ Muscle weakness ____Abnormal posture ____Muscle atrophy
____Tenderness ____Abnormal gait ____Crepitus ____Positive straight leg raising test
Other clinical findings:
Do emotional factors contribute to the severity of your patient’s symptoms
and functional limitations? ____Yes ____No
Identify any psychological conditions affecting pain:
____Depression ____Anxiety____Somatoform disorder ____Personality disorder
____Psychological factors affecting physical condition
Other:
How often is your patient’s experience of pain severe enough to interfere with attention and
concentration?
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
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Parent category: Medical