9 Medical Opinion Forms

These short-form residual functional capacity medical questionnaires from Dr. David A. Morton's Medical Issues in Social Security Disability can be great timesavers. In this roughly 50-page pamphlet, you receive these questionnaires:

Musculoskeletal

Major dysfunction of joins
Disorders of the spine
Soft Tissue Injuries

Heart

Hypertension
Valvular heart disease
Aneurysm of aorta

Mental

Organic mental disorders
Anxiety-related disorders
Personality disorders

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Major dysfunction of joints, disorders of the spine, soft tissue injuries, hypertension, valvular heart disease, aneurysm of aorta, organic mental disorders, anxiety-related disorders, and personality disorders

By David A. Morton

Excerpted from Medical Issues in Social Security Disability

MAJOR DYSFUNCTION OF JOINTS TREATING PHYSICIAN DATA SHEET

Short form

for representative use only

Representative’s Name and Address:

Representative’s Telephone:

Representative’s Email:

Physician’s Name and Address:

Physician’s Telephone:

Physician’s Email:

Patient’s Telephone:

Patient’s Name and Address:

Patient’s Email:

Patient’s SSN:

Level of Adjudication:

Initial DDS [ ] Recon DDS [ ]

Type of Claim: Initial CDR [ ] Hearing Officer [ ]

Title 2 [ ] DIB/DWB [ ] CDB Administrative Law Judge [ ] Appeals Council [ ]

Title 16 [ ] DI [ ] DC Federal District Court [ ] Federal Appeals Court [ ]

Dear Dr. _________,

We are pursuing the Social Security disability claim for the above-named individual (the “patient”). We understand how valuable your time is, and this data sheet has been designed to allow you to provide medical information in an efficient and organized way. As a treating physician, your records and medical judgment are vital in arguing for a fair disability determination for the patient before the Social Security Administration (SSA). If you receive multiple data sheets, please disregard repetitive questions.

Your medical specialty please:

Note 1: This document will not have legal validity for Social Security disability determination purposes unless completed by a licensed medical doctor or osteopath.

Note 2: This document only concerns joint dysfunction. Other impairments and limitations resulting from a combination of impairments should be considered separately.

Note 3: Age, degree of general physical conditioning, sex, body habitus (i.e., natural body build, physique, constitution, size, and weight), insofar as they are unrelated to the patient’s medical disorder and symptoms, should not be considered when assessing the functional severity of the impairment.

“Occasionally” means very little up to 1/3 of an 8 hour workday.

“Frequently” means 1/3 to 2/3 of an 8 hour workday.

I. What is the medical impairment (rheumatoid arthritis, traumatic arthritis, osteoarthritis, etc.) causing joint dysfunction?

II. Is there a history of chronic joint pain and stiffness?

[ ] Yes [ ] No [ ] Unknown

If Yes, when did the patient first complain to you of such symptoms?

Response of pain and stiffness to treatment:

[ ] Complete symptomatic relief

[ ] Partial symptomatic relief

[ ] No symptomatic relief

III. In the affected joints, is there significant limitation of motion?

[ ] Yes [ ] No [ ] Unknown

IV. Does the patient have gross anatomical deformity of any joint?

[ ] Yes [ ] No [ ] Unknown

If Yes, please check all that apply.

A. Hands/Wrist

[ ] Ulnar deviation [ ] One or [ ] both hands?

[ ] Swan-neck deformity [ ] One or [ ] both hands?

[ ] Boutonniere deformity [ ] One or [ ] both hands?

[ ] Contracture [ ] One or [ ] both hands?

[ ] Bony or fibrous ankylosis [ ] One or [ ] both hands?

[ ] Instability [ ] One or [ ] both hands?

[ ] Other (please specify) [ ] One or [ ] both hands?

B. Elbows