HA-1151 09-05 EDIT Medical Source Statement of Ability To Do Work-Related A

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REVISED MEDICAL ASSESSMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

NAME OF INDIVIDUAL	SOCIAL SECURITY NUMBER

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

The following terms are defined as:

 REGULAR AND CONTINUOUS basis means 8 hours a day, for 5 days a week, or an equivalent work

schedule.

 Occasionally means very little to one-third of the time.

 Frequently means from one-third to two-thirds of the time.

 Continuously means more than two-thirds of the time.

It is important that you relate particular medical findings to any assessed limitation in capacity:

The usefulness of your assessment depends on the extent to which you do this.

I. Lifting/Carrying

Check the boxes representing the amount the individual can lift and how often it can be lifted.

Lift	Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)
A. Up to 10 lbs:
B. 11 to 20 lbs:
C. 21 to 50 lbs:
D. 51 to 100 lbs:

Check the boxes representing the amount the individual can carry and how often it can be carried.

Carry	Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)
A. Up to 10 lbs:
B. 11 to 20 lbs:
C. 21 to 50 lbs:
D. 51 to 100 lbs:

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 or any limitations.

II. sitting/standing/walking

Please circle how many hours the individual can (If less than one hour, how many minutes):

At One Time without Interruption

Minutes Hours

A. Sit _____ 1 2 3 4 5 6 7 8

B. Stand _____ 1 2 3 4 5 6 7 8

C. Walk _____ 1 2 3 4 5 6 7 8

Total in an 8 hour work day

Minutes Hours

A. Sit _____ 1 2 3 4 5 6 7 8

B. Stand _____ 1 2 3 4 5 6 7 8

C. Walk _____ 1 2 3 4 5 6 7 8

If the total time for sitting, standing and walking does not equal or exceed 8 hours, what activity is the individual performing for the rest of the 8 hours?

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 or any limitations.

3. use of hands

Indicate how often the individual can perform the following activities:

ACTIVITY	Right Hand					Left Hand
	Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)		Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)
REACHING (Overhead)
REACHING (All Other)
HANDLING
FINGERING
FEELING
PUSH/PULL

Which is the individual’s dominant hand?  Right Hand  Left Hand

3. use of feet

Indicate how often the individual can perform the following activities:

ACTIVITY	Right Foot					Left Foot
	Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)		Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)
Operation of Foot Controls

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 or any limitations.

V. POSTURAL ACTIVITIES

How often can the individual perform the following activities:

Activity	Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)
Climb stairs and ramps
Climb ladders or scaffolds
Balance
Stoop
Kneel
Crouch
Crawl

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 or any limitations.

VI. DO ANY OF THE IMPAIRMENTS AFFECT THE CLAIMANT'S HEARING OR VISION?

No Yes Not Evaluated

If "yes" please complete the following questions (where appropriate).

1. If a hearing impairment is present,

a. Does the individual retain the ability to hear and understand simple oral instructions and to communicate simple information? Yes No

2. Can the individual use a telephone to communicate? Yes No

2. If a visual impairment is present,

1. Is the individual able to avoid ordinary hazards in the workplace, such as boxes on the floor, doors ajar, or approaching people or vehicles? Yes No

2. Is the individual able to read very small print? Yes No

3. Is the individual able to read ordinary newspaper or book print? Yes No

4. Is the individual able to view a computer screen? Yes No

4. Is the individual able to determine differences in shape and color of small objects such as screws, nuts or bolts? Yes No

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 or any limitations.

VII. Environmental Limitations

How often can the individual tolerate exposure to the following conditions:

Condition	Never	Occasionally (up to 1/3)	Frequently (1/3 to 2/3)	Continuously (over 2/3)
UnprotectedHeights
Moving Mechanical Parts
Operating a motor vehicle
Humidity
and wetness
Dust, odors, fumes and pulmonary irritants
Extreme cold
Extreme heat
Vibrations
Other: (Identify)

Condition	Quiet (Library)	Moderate (Office)	Loud (Heavy Traffic)	Very Loud (Jackhammer)
Noise

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 or any limitations.

VIII. PLEASE PLACE A check IN appropriate BOXES based solely on the claimant's

physical impairments.

ACTIVITY YES NO

Can the individual perform activities like shopping?
Can the individual travel without a companion for assistance?
Can the individual ambulate without using a wheelchair, walker, or 2 canes or 2 crutches?
Can the individual walk a block at a reasonable pace on rough or uneven surfaces?
Can the individual use standard public transportation?
Can the individual climb a few steps at a reasonable pace with the use of a single hand rail?
Can the individual prepare a simple meal & feed himself/herself?
Can the individual care for personal hygiene?
Can the individual sort, handle, use papers/files?

Please identify the medical findings that support this assessment (unless a narrative report is attached).

IX. State any other work-related activities, which are affected by ANY

IMPAIRMENTS, and indicate how the activities are affected. What are the

medical findings that support this assessment?

X. THE LIMITATIONS ABOVE ARE ASSUMED TO BE YOUR OPINION REGARDING

CURRENT LIMITATIONS ONLY.

hOWEVER, IF YOU HAVE SUFFICIENT INFORMATION TO FORM AN OPINION WITHIN a

REASONABLE DEGREE OF MEDICAL PROBABILITY AS TO PAST LIMITATIONS, on WHAT

date were the limitations you found above first present? __________________

xi. HAVE THE LIMITATIONS you found above LASTED OR WILL THEy LAST FOR

12 CONSECUTIVE MONTHS? YES NO

____________________________ _________________

SIGNATURE DATE

______________________________________________

Print Name, Title and Medical Specialty (Legibly Please)

PRIVACY ACT STATEMENT:

The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d), 1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act. The information on this form is needed by Social Security to complete processing of the named patient’s claim. While giving us the information on this form is voluntary, failure to provide the requested information may prevent an accurate or timely decision on the named patient’s claim. Although the information you furnish on this form is almost never used for any purpose other than making a determination about disability, such information may be disclosed by the Social Security Administration to another person or governmental agency only with respect to Social Security programs and to comply with federal laws requiring the exchange information between Social Security and another agency.

Explanations about these and other reasons why information about you may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT:

This information collection meets the clearance requirements of 44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 15 minutes to read the instructions, gather the necessary facts, and answer the questions.