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

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

Form Approved
OMB No.0960-0662

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.
FREQUENTLY means from one-third to two-thirds of the time.
CONTINUOUSLY 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 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 and why the findings
support the assessment.

Form HA-1151-BK (01-2015) ef (01-2015)
Destroy Prior Editions

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II. SITTING/STANDING/WALKING
Please check 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

Minutes

Total in an 8 hour work day
Hours
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

A. Sit

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?

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

Yes

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?

.

With a cane, can the individual use his/her free hand to carry small objects?

Yes

No
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 and why the findings
support the assessment.

Form HA-1151-BK (01-2015) ef (01-2015)

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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)

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

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

Right Foot
Never

Left Foot

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

Continuously
(over 2/3)

Never

Occasionally Frequently
(up to 1/3) (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 and why
the findings support the assessment.

Form HA-1151-BK (01-2015) ef (01-2015)

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V. POSTURAL ACTIVITIES
How often can the individual perform the following activities:
ACTIVITY

Never

Climb stairs and ramps

Occasionally
(up to 1/3)

Frequently
(1/3 to 2/3)

Continuously
(over 2/3)

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 and why
the findings support the assessment.

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
Yes
No
to communicate simple information?
Yes

b. Can the individual use a telephone to communicate?

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
Yes
No
floor, doors ajar, or approaching people or vehicles?
b. Is the individual able to read very small print?

Yes

No
Yes

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

Yes

No

No

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

Form HA-1151-BK (01-2015) ef (01-2015)

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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 2/3)

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)

Noise

Loud
(Heavy
Traffic)

Very Loud
(Jackhammer)

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 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 their personal hygiene?
Can the individual sort, handle, or 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 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?
No
Yes
XII. DID YOU EXAMINE THE CLAIMANT?

Yes

No

I DECLARE UNDER PENALTY OF PERJURY THAT I HAVE EXAMINED ALL THE
INFORMATION ON THIS FORM, AND ON ANY ACCOMPANYING STATEMENTS OR
FORMS, AND IT IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

SIGNATURE

DATE

Print Name, Title and Medical Specialty (Legibly Please)
Form HA-1151-BK (01-2015) ef (01-2015)

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Privacy Act Statement
Medical Source Statement of Ability to do Work-Related Activities
(Physical)
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. We will use the information you provide to determine the individual's ability to
perform (mental) work-related activities on a sustained basis.
The information you furnish on this form is voluntary. However, failure to provide the requested information
may affect our ability to make an accurate assessment of the individual's mental ability to perform a work
related activity.
We rarely use the information you supply for any purpose other than for the reasons explained above.
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 of delinquent debts
under these programs.
A complete list of routine uses for this information is available in our System of Records Notice entitled,
Completed Determination Record - Continuing Disability Determinations, 60-0050. This notice,
additional information regarding this form, and information regarding our programs and systems, is
available on-line at http://www.socialsecurity.gov or at your local Social Security office.

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
w ill take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed
underU. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). 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 (01-2015) ef (01-2015)

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