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NAME OF INDIVIDUAL SOCIAL SECURITY NUMBER

To determine this individual’s ability to do work-related activities on a day-to-day basis in a regular work
setting, please give us an assessment BASED ON YOUR EXAMINATION of how the individuals physical
capabilities are affected by the impairment(s). Consider the medical history, the chronicity of findings or
lack thereof, and the expected duration of any work-related limitations, but not the individual’s age, sex or
work experience. Attach all relevant treatment notes, radiologist reports, laboratory and test results which
have not been provided previously to the Social Security Administration

For each activity shown below:

1. Check the appropriate block;

2. Respond to the questions concerning the individuals ability to perform the activity; and
3._Identify the particular medical findings (i.e. physical exam findings, x-ray findings, laboratory
Test results, history, symptoms (including pain) etc.) which support your assessment of any
limitations.

IT IS IMPORTANT THAT YOU RELATE PARTICULAR MEDICAL FINDINGS TO ANY ASSESSED

REDUCTION IN CAPACITY:THE USEFULNESS OF YOUR ASSESSMENT DEPENDS ON THE
EXTENT TO WHICH YOU DO THIS:
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I. Are LIFTING/CARRYING_ What are the medical findings that support this?
affected by impairment?
( ) No
( ) Yes
If yes, how many pounds can the
individual lift and/or carry? __________

Maximum occasionally (from very little

up to 1/3 of an 8 hour day) __________

Maximum frequently (from 1/3 to 2/3

of an 8 hour day) __________
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II. Are STANDING/WALKING_ What are the medical findings that support
this?
affected by impairment?
( ) No
( ) Yes
If yes, how many hours in an
8 hour work day can the individual
stand and/or walk? Total ________

without interruption? ___________

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III. Is SITTING What are the medical findings that support this?
affected by impairment?
( ) No
( ) Yes
If yes, how many hours in a regular
8 hour work day can the individual
sit? Total ________

without interruption? ___________

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IV. How often can the individual_ What are the medical findings that support this?
perform the following POSTURAL
ACTIVITIES?

Frequently* Occasionally ** Never

Climb
Balance
Stoop *Frequently: from 1/3 to 2/3 of 8-hour day
Crouch **Occasionally: from very little up t 1/3 of
Kneel 8-hour day
Crawl
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V. Are the following PHYSICAL __ A. How are these physical functions
affected?
FUNCTIONS affected by the
impairment?

No Yes
Reaching
Handling
Feeling
Pushing/Pulling
Seeing
Hearing B. What are the medical findings that support
Speaking this assessment
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VI. Are there ENVIRONMENTAL _ A. How do the checked restrictions affect?
RESTRICIONS caused by the the individuals activities?
impairment?

No Yes
Heights
MovingMachinery
TemperatureExtremes
Chemicals
Dust
Noise
Fumes
Humidity B. What are the medical findings that support
Vibration this assessment?
Other
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VII. State any other work-related activities which are affected by the impairment, and indicate how the
activities are affected. What are the medical findings that support this assessment?

ONSET DATE OF ABOVE LIMITATIONS __________________________________

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PHYSICIANS SIGNATURE DATE