Residual Functional Capacity Ssa Listed Disorders Page 6

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_____ YES, but a morning break, a lunch period, and an afternoon break
scheduled at approximately two hour intervals is sufficient.
_____ NO, rest lying down or in a supine position in bed or in an easy chair
is not medically indicated.
B) If so, WHY does the patient need REST for some period of time during an 8
hour work day? (Check one please)
_____ To relieve pain arising from a documented medical impairment
_____ To relieve fatigue arising from a documented medical impairment
_____ Non-Applicable. rest as defined is not medically indicated.
C) If so, what is the TOTAL CUMULATIVE resting/lying down or reclining in a
supine position needed during an eight hour work day?
Less than 1 hr --- 1 hr --- 2 hrs --- 3 hrs --- 4 hrs --- 5 hrs --- 6 hrs --- Less than 6
hrs
14. LIFTING AND CARRYING (Check one at each weight level)
Weight in Pounds: 1-5 lbs.
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
Weight in Pounds: 6-10 lbs.
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
Weight in Pounds: 11-20 lbs.
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
Weight in Pounds: 21-50 lbs.
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess
15. BALANCING when standing/walking on level terrain (check one)
Never
Occasionally
Frequently
Constantly
No
Not Able to Assess

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