MEDICAL OPINION – PHYSIOLOGICAL CONDITIONS

Please complete the following questions based upon your personal treatment of the patient. Your opinion should be based on your findings with respect to medical history, clinical and laboratory findings, diagnosis, prescribed treatment, including side effects of medications, response to treatment, and prognosis.

1) Please state the date that you first start treating   :  
2) Please describe your professional qualifications, licensure, areas of specialization, and board certifications (in lieu of completing this section, please attach a copy of your curriculum vitae):  
3) Please list all of your patient’s diagnoses for which you have provided treatment: 

To determine this individual’s ability to do work-related activities on a regular and continuous basis, please give us your opinion for each activity shown below.

In the tables below, please put an “X” in the appropriate boxes.

4) NON-EXERTIONAL LIMITATIONS

a) How much is the patient likely to be “off-task”? That is, how much of a typical workday would your patient’s symptoms likely be severe enough to interfere with the attention and concentration needed to perform even simple work-related tasks?

0 5% 10% 15% 20% 25% >25%

b) How long is your patient able to maintain attention and concentration before requiring a break?

<5 min <15 min <30 min <1 hour <2 hour 2 hours

c) Assuming was trying to work full time, please estimate, on average, how many days per month your patient is likely to be absent from work as a result of the medical impairments and/or treatment:

0 1 2 3 4 4+

d) Would the limitations noted above stem from any of the following:

  •  
  •  
  •  
  •   

e) Please indicate on the diagram where your patient experiences pain:


5) LIFTING/CARRYING (Maximum In Pounds)
Patient Can Lift/Carry
Never Rarely Occasional Frequent Continuous
<10
10
20
50
100
>100

NEVER means not even once in an 8-hour work day
RARE means 1% to 5% of an 8-hour work day OCCASIONAL means 6% to 33% of an 8-hour work day FREQUENT means 34% to 66% of an 8-hour work day CONTINUOUS means 67% to 100% of an 8-hour work day

Identify the particular medical or clinical findings (i.e. physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment of limitations and why the findings support the assessment:

6) SITTING/STANDING/WALKING
Total Hours in an 8-Hour Work Day Does your patient require the
option to sit/stand at-will?
<1 1 2 3 4 5 6 7 8
Sit
Stand/Walk     
a) Does the patient require the option to lie down or recline throughout the workday?      
If yes, please answer the following:
  • How often would your patient need to lie down/recline during an 8-hour workday:

  • For how long would your patient need to lie down/recline each time:
b) With sitting, should your patient's leg(s) be elevated?     
c) Does your patient need a cane or other assistive device, at least sometimes?      
If yes, please answer the following:
  • What assistive device(s) your patient require:  

  • How far can your patient ambulate without the use the device?  
d) Would your patient have limitations using foot controls?      
Never Rarely Occasional Frequent Continuous
Left Foot
Right Foot

Identify the particular medical or clinical findings (i.e. physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment of limitations and why the findings support the assessment: 

7) USE OF HANDS
Dominant Hand
     		 Left Arm/Hand Right Arm/Hand
Never Rarely Occasional Frequent Continuously Never Rarely Occasional Frequent Continuously
Reaching overhead
Reaching all other
Handling
Fingering
Feeling
Pushing/pulling

Identify the particular medical or clinical findings (i.e. physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment of limitations and why the findings support the assessment: 

8) POSTURAL ACTIVITIES
Never Rarely Occasional Frequent Continuously
Balance
Stoop
Kneel
Crouch
Crawl
Rotate head and/or neckg

Identify the particular medical or clinical findings (i.e. physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment of limitations and why the findings support the assessment:

9) ENVIRONMENTAL LIMITATIONS
Never Rarely Occasional Frequent Continuously
Dust/Odors/Fumes/Pulmonary Irritants
Extreme Cold
Extreme Heat
Operating a Vehicle

Identify the particular medical or clinical findings (i.e. physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment of limitations and why the findings support the assessment:

I have formed these medical opinions based upon my personal treatment of including my knowledge of the patient’s medical history, clinical and laboratory findings, diagnosis, prescribed treatment, side effects of medications, response to treatment, my training, education and experience.

If this form was completed by a provider without credentials as an MD, DO, DPM, Physician Assistant, Nurse Practitioner or similar, please include a co-signature from a provider with such credentials: