Form HA-1151 Medical Source Statement of Ability to Do Work-Related A

Form Approved

OMB No. 0960-0662

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

MEDICAL SOURCE STATEMENT OF

ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

SOCIAL SECURITY NUMBER

NAME OF INDIVIDUAL

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.
• FREQlIENTLY means from one-third to two-thirds of the time.
• CON1"NUOUSLY means more than two-thirds of the time.
Age and body habitus of the individual should not be considered in the assessment of limitations. It is
important that you relate particular medical or clinical findings to any assessed limitations 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

Never Occasionally
(up to 1/3)

lift and how often it can be lifted.

Frequently

(1/3 to 2/3)

Continuously
(over 2/3)

A. Up to 10 Ibs:
B. 11 to 20 Ibs:
C. 21 to 50 Ibs:
D. 51 to 100 Ibs:

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 Ibs:
B. 11 to 20 Ibs:
C. 21 to 50 Ibs:
D. 51 to 100 Ibs:

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 and why the findings
support the assessment.

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II. SITTING/STANDINGIWALKING
Please check how many b.Q\.@ the individual can (If less than one hour, how many minutes):
At Qne Time withoyt Interru(;2tion
.I::!ru@

Minutes

01 02 03 04 05 06 07 08
01 02 03 04 05 06 07 08

01 02 03 0 4 05 06 07 08

A. Sit
B. Stand
C.Walk

Iotgl in ~n 8 hour wQ[is. d~!i
MiJl~

A. Sit
B. Stand
C.Walk

Hours

01 02 03 04 05 06 07 08
01 02 03 04 05 06 07 08

01 02 03 04 05 06 07 08

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?

DYes

Does the individual require the use of a cane to ambulate?

0

No

If the answer is "yes" please answer the following:
•

How far can the individual ambulate without the use of a cane?

•

Is the use of a cane medically necessary?

0

Yes

0

No

• Without a cane, can the individual use his/her free hand to carry small objects?

0

Yes

0

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 and why the findings
support the assessment.

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-.~ .. ~..-------~

III. USE OF HANDS

Indicate how often the individual can perform the following activites:

ACTIVITY

Right Hand
Never

Occasionally
(up to 1/3)

Left Hand

Frequently
(1/3 to 2/3)

Never

Continuously
(over 2/3)

Occasionally Frequently
(up to 1/3)
(1/3 to 2/3)

Continuously
(over 2/3)

REACHING
(Overhead)
REACHING
(All Other)
HANDLING
FINGERING
FEELING
PUSH/PULL

0

Which is the individual's dominant hand?

Right Hand

0

Left Hand

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 and why
the findings support this assessment.

IV. USE OF FEET
Indicate how often the individual can perform the following activities:
ACTIVITY

Left Foot

Right Foot
Never

Occasionally Frequently
(up to 1/3) (113 to 2/3)

Continuously
(over 2/3)

Never

Occasionally Frequently
(up to 1/3) (1/3 to 213)

Continuously
(over 2/3)

Operation of
Foot Controls

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

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V. POSTURAL ACTIVITIES

How often can the individual perform the following activities:

Never

ACTIVITY

Occasionally
(up to 1/3t

Frequently

Continuously
lover 2/31

(1/3 to 2/3t

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 ....ay findings, laboratory test
results, history, and symptoms including pain etc.) which support your assessment or any limitations and why
the findings support the assessment.

VI. DO ANY OF THE IMPAIRMENTS AFFECT THE CLAIMANTS HEARING OR VISION?

o

No

0

Yes

0

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

0

0

b. Can the individual use a telephone to communicate?

0

0

Yes

No

2. If a visual impairment is present,
a. Is the individual able to avoid ordinary hazards in the workplace, such as boxes on the

floor, doors ajar, or approaching people or vehicles? 0 Yes 0 No

b. Is the individual able to read very small print?

0

Yes

0

No

c. Is the individual able to read ordinary newspaper or book print?
d. Is the individual able to view a computer screen?

0

Yes

0

0

Yes

0

No

No

e. Is the individual able to determine differences in shape and color of small objects such as

screws, nuts or bolts? 0 Yes 0 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 and why
the findings support the assessment.

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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 213)

Continuously
(over 2/3)

Unprotected
Heights
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 and why the findings
support the assessment.

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VIII. PLEASE PLACE A CHECK IN APPROPRIATE BOXES BASED SOLELY ON THE CLAIMANTS
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 paper/files?

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

IX. STATE ANY OTHER WORK-RELATED ACTIVITIES, WHICH ARE AFFECTED BY ANY IMPAIRMENTS,

AND INDICATE HOW THE ACTNITIES ARE AFFECTED. WHAT ARE THE MEDICAL FINDINGS -rHAT

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

0

0

DATE

SIGNATURE

Print Name, Title and Medical Specialty (Legibly Please)

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PRIVACY ACT STATEMENT:

See revised Privacy Act and Paperwork
Reduction Act statements below.

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. You may send comments on
our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Form HA-1151-BK (06-2006) ef (8-2006)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act, as
amended, authorize us to collect this information. The information you provide will be
used to complete processing of the named patient’s claim.
The information you furnish on this form is voluntary. However, failure to provide the
requested information may prevent an accurate or timely decision on the named patient’s
claim.
We rarely use the information you supply for any purpose other than for determining
eligibility for benefits. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.ssa.gov or at your local Social
Security office.

Revised Paperwork Reduction Act Statement – OHA Forms
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 15
minutes to read the instructions, gather the facts, and answer the questions. You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.