|
§175.1 ANALYSIS
Name: ____________________________________
DOB _________________
Theory:
___________________________________________________________
__________________________________________________________________
Med-Voc Rule__________
Listings §___________ Alleged Onset:______________
DLI:_____________
Issues: ____________________________________________________
__________________________________________________________
__________________________________________________________
|
ATTORNEY'S RANKING OF IMPAIRMENTS |
ASSOCIATED SYMPTOMS |
| 1. |
1. |
| 2. |
2. |
| 3. |
3. |
| 4. |
4. |
| 5. |
5. |
Date Last Worked: ____________
Age today: ________ Age at
onset: ________
*Past 15 years or 15 years before date last insured, if
earlier.
** Enter C for customary, E for easiest job.
|
Dates |
Occupation* |
Strength
Level |
Skill
Level |
DOT No. |
C/E** |
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
Unable to do easiest job because:
___________________________________________________________
Limited to: □ less
than sedentary □ alt sit/stand
□ sedentary
□ light
□ medium
Mental limitations: _________________________
Work skills: _____________________
Highest Grade Completed: _______
Vocational Training: __________________________
□ Check here if abilities appear less than level of
schooling would indicate.
Summary of
Physical Residual Functional Capacity
□
_________________________________ says that s/he can walk about
_____ blocks before stopping.
□ S/he can sit for about
_____ minutes at one time and stand for about _____ minutes at one time.
□ Out of an 8-hour working
day, s/he says s/he can sit for a total of hours
and stand/walk for a total of hours.
□ S/he needs to walk around
approximately every _____ minutes for about _____ minutes.
□ S/he needs a job that
permits shifting positions at will.
|
□
|
muscle weakness
|
□
|
pain/ paresthesias, numbness
|
□
|
_________________
|
|
□
|
chronic fatigue
|
□
|
adverse effects of medication
|
□
|
_________________
|
Because of
s/he may need to take unscheduled breaks [¨ to lie down]
during an 8-hour working day. S/he expects this to happen
______________________________; and s/he may need to rest ___________
minutes (on average) before returning to work.
□ If s/he had a sedentary job, because of
___________________________ s/he says s/he would need to elevate his/her
legs about _____% of the time during an 8-hour working day. S/he
needs to elevate his/her legs about _____ high.
□ S/he needs a cane to walk because of
|
□
|
imbalance
|
□
|
pain
|
□
|
weakness
|
□
|
dizziness
|
|
□
|
insecurity
|
□
|
________________________________________
|
□ S/he can occasionally
lift and carry _____ lbs. and frequently lift and carry _____ lbs.
S/he says that because of
|
□
|
pain/ paresthesias
|
□
|
motor loss
|
□
|
sensory loss/ numbness
|
|
□
|
muscle weakness
|
□
|
swelling
|
□
|
side effects of medication
|
|
□
|
limitation of motion
|
□
|
_______________________________________
|
s/he has significant limitations in reaching, handling,
and fingering.
|
S/he can use her/his left hand for
|
|
S/he can use her/his right hand for
|
|
grasping _____% of the time,
|
|
grasping _____% of the time,
|
|
fingering _____% of the time,
|
|
fingering _____% of the time, and
|
|
reaching overhead _____% of the time, and
|
|
reaching overhead _____% of the time, and
|
|
reaching in front of body _____% of the
time.
|
|
reaching in front of body _____% of the
time.
|
□ S/he says that s/he
can
|
never
|
rarely
|
occasionally
|
frequently
|
|
|
□
|
□
|
□
|
□
|
twist,
|
|
□
|
□
|
□
|
□
|
stoop (bend),
|
|
□
|
□
|
□
|
□
|
crouch/ squat,
|
|
□
|
□
|
□
|
□
|
climb ladders, and
|
|
□
|
□
|
□
|
□
|
climb stairs.
|
□ S/he says that s/he
can
|
never
|
rarely
|
occasionally
|
frequently
|
|
|
□
|
□
|
□
|
□
|
look down (sustained flexion of neck),
|
|
□
|
□
|
□
|
□
|
turn head right or left,
|
|
□
|
□
|
□
|
□
|
look up, and
|
|
□
|
□
|
□
|
□
|
hold head in static position.
|
□ S/he says that s/he
has the following environmental limitations:
________________________________________________________________________
________________________________________________________________________
□
S/he says that her/his symptoms (often) (frequently) (constantly) are
severe enough to interfere with
attention and concentration.
□ S/he says that as a result of his/her impairments
s/he has a (moderate) (marked) (severe) limitation in dealing with work
stress.
□ Because of bad
days, s/he says that if s/he had a full-time job s/he expects that s/he
would miss work
about/more than ___ times a
month.
VISION
□ S/he says that s/he
can
|
never
|
rarely
|
occasionally
|
frequently
|
constantly
|
|
|
□
|
□
|
□
|
□
|
□
|
utilize near acuity,
|
|
□
|
□
|
□
|
□
|
□
|
utilize far acuity, and
|
|
□
|
□
|
□
|
□
|
□
|
utilize depth perception.
|
□ S/he is incapable
of avoiding ordinary hazards in the workplace, such as boxes on the
floor, doors ajar, approaching people or vehicles.
□ S/he has difficulty
walking up or down stairs because of his/her vision.
□
S/he says s/he cannot work with small objects such as those involved in
doing sedentary work.
□ S/he can/ cannot
work with large objects.
□ Other: _____________________________________________________
__________________________________________________________
|
NOW
|
DOCTORS TO GET RFC
OPINIONS FROM
|
TYPE OF
RFC FORM
|
OTHER RECORDS THAT SSA MAY NOT HAVE OBTAINED
|
|
|
1.
|
|
1.
|
|
|
2.
|
|
2.
|
|
|
3.
|
|
3.
|
|
|
4.
|
|
4.
|
|
LONG TERM DISABILITY CARRIER
|
OTHER RECORDS NEEDED
|
|
Name:
|
□ SS file from local office
□ Work records - employer:________________
|
|
Address:
|
□ Vocational rehabilitation records
□ L.T.D. carrier records
|
|
|
□ School records
□ Driving record
|
|
|
□ Other:_________________________________
□ Other:_________________________________
|
□ Flag to work up for
possible on-the-record decision. Impression: __________________
□ Request postponement of hearing scheduled for
_________ with ALJ ______________
OTHER THINGS TO DO
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
THINGS OUR CLIENT WILL SEND US
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
1-25
2/04
§175.1
Copyright 2009 James Publishing
|
