Residual Functional Capacity Form

Patient: ________________ SS #: _______________

Date of Birth:_____________________

Dear Doctor:______________________

Please respond to the following questions regarding your patient s disability. This will be used as

medical evidence for a ocial ecurity disability claim or a private long term disability claim.

Please be specific with regards to your patient’s medical ailments and how they affect his

or her daily activities both at work and at home:

1. With regards to your contact with the patient, please describe the frequency and

purpose:

2. Please describe the patient’s symptoms as completely as possible:

3. Please state all clinical findings and any medical test results and/or laboratory results:

4. What is your diagnosis of the patients symptoms and test results?

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Parent category: Medical