Residual Functional Capacity Ssa Listed Disorders Page 9
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13B) If so, what TYPE of hand-held assistive device is medically required?
___ Cane
___ Walker
___ 2 Crutches
___ 1 Crutch
C) If so, in what CIRCUMSTANCES is the hand-held assistive device medically
required?
___ On ALL surfaces and terrains for all ambulation
___ ONLY on uneven surfaces and terrains or slopes
___ ONLY for prolonged ambulation?
Are your patient’s impairments likely to produce “good days” and “bad days”?
If yes, please estimate, on the average, how often your patient is likely to be absent from
work as a result of the impairments or treatment: (Circle One)
___ Never ___ About twice a month ___ Less than once a month _
About 3 times a month___ About once a month ___ More than 3 times a month
If the patient has any complaints of pain, please address the following questions:
What is the nature of the pain?
Is there an objective reason for the pain supported by medical evidence?
How frequent is the pain?
What is the level of pain on a scale of one to ten?
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