Disorders of the Spine
To: Social Security Administration Re: _____________________________________(Name of Patient)
_____________________________________(Social Security No.)
Are there any of the following disorders of the spine present with the patient:
Yes No
____ ____ Herniated nucleus pulposus
____ ____ Spinal archnoiditis
____ ____ Spinal stenosis
____ ____ Osteoarthritis
____ ____ Degenerative disc disease
____ ____ Facet arthritis
____ ____ Vertebral fracture
A. Is there evidence of any of the following?
Yes No
____ ____ Nerve Root Compression
____ ____ Limitation of motion of the spine
____ ____ Motor loss (atrophy w/associated muscle weakness)
____ ____ Muscle weakness
____ ____ Sensory or reflex loss
____ ____ Involvement of the lower back
____ ____ Positive straight-leg raising test (sitting and supine)
B. Is there evidence of spinal arachnoid, confirmed by and of the following?
Yes No
____ ____ Operative note
____ ____ Pathology report of tissue biopsy
____ ____ Medically accepted imaging
____ ____ Manifested by severe burning
____ ____ Painful dysesthesia, resulting in the need for changes in
position or posture more than once every 2 hours
C. Is there evidence of lumbar spinal stenosis resulting in pseudoclaudication, established by any of the following?
Yes No
____ ____ Findings on appropriate medically acceptable imaging
____ ____ Manifested by chronic nonradicular pain and weakness
____ ____ resulting in inability to ambulate effectively
Earliest date of symptoms checked above: _____________________.
____________________________________ ___________________________
Physician’s Signature Date form completed
Printed/Typed Name: __________________________________________
Address: __________________________________________
__________________________________________
__________________________________________
Return form to:
Mike Murburg, PA
15501 N. Florida Ave
Tampa, FL 33613
Tel: 813-264-5363
Fax: 813-514-9788
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