New railroad Retirement Board Disability and Social Security Disability Physical RFC Form

                   PHYSICAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE

   RE:     Patient: _________________________________________________          SS#: ___________________________________________________

Please answer the following concerning your patient’s impairments and any reasonable restrictions.

1. Frequency and length of contact: __________________________________________________________
2. Diagnoses: __________________________________ _____________________________________ ___________________________________ ________________________________
3. Prognosis: _________________________________________________________________________
4. List your patient’s symptoms, including pain, dizziness, fatigue, etc.:   ___________________________________________________________________
5. Identify clinical findings and objective signs: _________________________________________________________________________________________
6. If your patient has pain, characterize the nature, location, frequency, precipitating factors, and severity, of your patient’s  pain: _________________________________________________________________________________________________________________________
7. Describe the treatment and response including any side effects of medication that may have implications for any potential for working, e.g., drowsiness, dizziness, nausea, etc._______________________________________________________________________________________
8. Have your patient’s impairments lasted or can they be expected to last 12 months?   ____ yes ____ no
9. Do emotional factors contribute to the severity of the patient’s symptoms or functional limitations? ____ yes   ____ no
10. Identify any psychological conditions affecting your patient’s physical condition:   __ Anxiety   __ Depression __Somatoform            Disorder __ Personality Disorder __ Other: ________________________________________________________________________
11. Are your patient’s impairments (physical impairments plus any emotional impairments) reasonably consistent with the symptoms and functional limitations described in the evaluation? ____ yes   ____ no
12. To what degree can patient tolerate work stress (i.e., maintain persistence and pace required within the confines of competitive work)? ___ Incapable of “low stress” ___ Capable of “low stress” ___ Moderate stress   ___ High stress work
13. As a result of your patient’s impairments, estimate your patient’s functional limitations if your patient were placed hypothetically in a competitive work situation:
14. How many blocks can the patient reasonably walk without rest or significant pain? _______________ blocks
15. Please circle the hours and/or mins. that the patient can sit comfortably at one time, without significant distraction from pain or symptomatology before needing to get up, etc.: Sit:   0 5 10 15 20 30 45 Minutes 1 2 Hrs. > than 2 Hrs
16. Please circle the hrs. and/or mis. that your patient can stand at one time, e.g., before needing to sit or, walk around, etc.

Stand: 0   5   10   15   20   30   45   Minutes    1   2 Hrs       More than 2 Hours

1. Please indicate how long your patient can sit and stand/walk total in an 8-hour working day (with normal breaks)

Sit                         Stand/Walk

___                                                                                    ___                 less than 2 hours

___                                                                                    ___                 about 2 hours

___                                                                                    ___                 about 4 hours

___                                                                                    ___                 at least 6 hours

1. Does patient require periods of walking around during an 8hr. working day?               ____ yes   ____ no

1) If yes, how often must your patient walk? 1 5 10 15 20 30 45 60 90 Minutes

2) Length of walk each time? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Minutes

1. Does patient need job permitting shifting positions at will ?                         ____ yes ____ no

1. Will patient need unscheduled breaks in an 8-hour work day? ____ yes ____ no If Yes, please answer 1) & 2) below.

1) How often do you think this will happen? ________________________________

2) What is the average length of time the patient will have to rest before returning to work? _________ Mins __________ Hrs

1. With prolonged sitting, will patient’s leg(s) need elevation at/above waist level?            ____ yes   ____ no

1) What percentage of time during an 8-hour working day should the patient’s leg(s) be elevated? _______________________%

2) Will the patient use a cane or other assistive device?                                                    ____ yes   ____ no

Regarding the questions contained within this form “Rarely” means 1% to 5%:“Occasionally” means 6% to 33%;“Frequently” means 34% to 66%:“Constantly” means 67% or more of an 8-hour working day.

14. a. How many pounds can your patient lift and carry in a competitive work situation?

Never           Rarely              Occasionally            Frequently

Less than 10 lbs.              __                      __                    __                      __

10 lbs.                                                                __                      __                    __                     __

20 lbs.                                                               __                      __                    __                      __

50 lbs.                                                               __                      __                     __                      __

1. How often can your patient perform the following activities?

Never          Rarely          Occasionally            Frequently

Look down (sustained)     __                      __                    __                      __

Turn head right or left     __                     __                     __                     __

Look up                         __                     __                    __                     __ Hold head in static         __                     __                    __                   __

Position

1. How often can the individual perform the following Physical Functions?

Never                      Rarely             Occasionally             Frequently

Reaching                                                __                      __                   __                        __

Handling                                                __                     __                      __                      __

Feeling                                                              __                     __                     __                     __

Pushing/Pulling                                      __                   __                     __                     __

Hearing                                                            __                     __                     __                      __

Speaking                                                __                     __                     __                      __

1. How often can your patient perform the following activities?

Never           Rarely           Occasionally               Frequently

Twist                                                                 __                     __                      __                     __

Stoop (bend)                                          __                      __                     __                     __

Crouch/squat                                         __                      __                      __                     __

Climb ladders                                         __                     __                      __                     __

Climb stairs                                            __                      __                      __                     __

Kneel                                                                 __                     __                      __                      __

Crawl                                                                __                     __                     __                     __

Balance                                                              __                      __                     __                     __

1. Does the patient have any limitations w/ reaching, handling or fingering? ____ yes   ____ no

If yes, please explain: ________________________________________________________________________________________________________________.

1. How frequently during a typical workday how would you reasonably anticipate that your patient’s experience of pain or other symptoms including the effects or side effects of medications would be severe enough to interfere with attention and concentration needed to perform even simple repetitive tasks?

__ Never         __ Rarely                __ Occasionally           __ Frequently             __ Constantly         

15. Will patient’s condition produce “good days” and “bad days”? ____ yes ____ no

If yes, please estimate, on the average, how many days per month your patient is likely to be absent from work as a result of the impairments or need for treatment.

__ never   __ about 1 day/mo.   __ about 2 days/mo.     __ about 3 days/mo. __ about 4 days/mo.   __ more than 4 days/mo.

16. Please describe any other limitations (such as psychological limitations, vision, hearing, need to avoid temperature extremes, wetness, humidity, noise, dust, fumes, gases, heights or hazards, etc.) that would affect your patient’s ability to work at a regular job on a sustained basis: _____________________________________________________________________________________________________________

17. What is the earliest date the symptoms and limitations described above in this questionnaire apply?   ___________________ (Date of Earliest Application of symptoms)

Physician’s Signature: _______________________________________________                                                Date Completed: ____________________

Printed/Typed Name: ______________________________________________

Address: ________________________________________________________________                 Or Please Attach Physician’s Business Card hereunder.

_________________________________________________________________  

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