Residual Functional Capacity Ssa Listed Disorders Page 3

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To what degree is your patient limited in the ability to deal with work stress?
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
MEDICATIONS
List Prescribed Medications and identify condition for which medications are prescribed.
Identify the side effects of any medication which may have implications for working, e.g.,
dizziness, drowsiness, stomach upset, etc.
Is there a reasonable medical probability your patient will experience side effects from the
medication(s) listed above?
Yes
No
Other:
To what degree will the side effects of the prescribed medications impair your patient’s ability
for concentration, persistence and pace in combination with the underlying condition(s)?
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
When side effects exist can you estimate the severity?
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Is your patient allowed to operate machinery or motorized vehicles when experiencing side
effects from the medication?
Yes
No
Is there a reasonable medical probability that the side effects will reduce your patient’s ability to
perform work to a minimum standard of productivity? If yes, to what degree:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
Is there a reasonable medical probability that the side effects will reduce your patient’s ability to
perform detailed work requiring hand/eye coordination? If yes, to what degree:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess

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Parent category: Medical