Residual Functional Capacity Ssa Listed Disorders Page 4

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Is there a reasonable medical probability that the side effects will reduce your patient’s cognitive
acuity and/or ability to focus on activities such as reading, writing, computer use? If yes, to what
degree:
Mild
Slight
Moderate
Severe
Other
Not Able to Assess
11. Please mark the activities the patient CAN perform on a regular and continuing basis. ‘A
regular and continuing basis” means 8 hours a day for 5 days a week, or an equivalent work
schedule.
SITTING in a working position at a desk or table without reclining.
A) MAXIMUM CONTINUOUSLY sitting before alternating postures standing or
walking about. (Circle one please)
Less than15 min --15 min --- 1 hr --- 2 hrs --- 3 hrs --- less than 3 hrs
B) After sitting for the maximum continuous period, does this patient need
to ALTERNATE POSTURES by standing or walking about? (Check one please)
___ YES, by walking about.
___ YES, but standing in place is sufficient
___ NO, alternating postures is not medically indicated.
C) If so, HOW LONG does the patient need to stand or walk about before returning
to a seated position for another maximum continuous interval? (Circle one please)
Less than15 min --15 min --- 1 hr --- 2 hrs --- 3 hrs --- less than 3 hrs
D) Is it medically necessary for this patient to elevate the legs while SITTING
to minimize pain? (check one please).
____ Yes, BOTH legs
____ Yes, RIGHT leg only
____ Yes, LEFT leg only
____ No, it is not necessary to elevate either leg while sitting.
E) If elevation of the patient’s legs is medically necessary, what DEGREE of elevation is
appropriate?
____ Elevation to chest level or higher

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