How to Get On

Residual Functional Capacity FormPatient: ___________________________SS #: __________________________ Date of Birth: ______________________ Claim #: _______________________Dear Doctor:Please respond to the following questions regarding your patient’s disability. This will be used as medical evidence for a social security disability claim. Please be specific with regards to your patient’s medical ailments and how they affect his or her daily activities both at work and at home:1. With regards to your contact with the patient, please describe the frequency and purpose: ___________________ began seeing me in January 2017, shortly after she moved to ________________. Prior to moving here, she had previously been diagnosed with lupus by Dr. ___________________; and diagnosed with fibromyalgia many years ago by Dr. ____________________. Since the beginning of last year, I have been monitoring her Systemic Lupus Erythematosus and Fibromyalgia. Patient is seen in my office every 3 months, with an upcoming appointment on __________________.2. Please describe the patient’s symptoms as completely as possible: Patient’s main ongoing symptoms are chronic joint and muscle pain and weakness, pain in fingers/hands, back pain, osteoarthritis and inability to use knees (cannot use stairs or bend knees), extreme fatigue, brain fog, depression, frequent insomnia, migraines, skin rash especially when exposed to sun or fluorescent lights (photosensitivity), severe sicca sx - especially dry eyes and meibomian gland dysfunction which has caused cornea erosions (diagnosed and treated by Dr. _________________), severe heartburn from gastritis and esophagitis (diagnosed and treated by Dr. _______________________, and stage 3 kidney disease and nephritis (diagnosed and treated by Dr. _______________________).3. Please state all clinical findings and any medical test results and/or laboratory results:maintains the following: +ANA+dsDNAElevated inflammatory markers / sed rateAbnormal urinalysis for past year and a half, tested every 3 months (high WBC, hematuria, high sediment) Low GFR for past year indicating stage 3 kidney disease (nephrologist has scheduled kidney biopsy)4. What is your diagnosis of the patients symptoms and test results?Systemic Lupus ErythematosusFibromyalgiaStage 3 kidney disease, lupus nephritis5. Please describe any treatments done so far and the results of treatment. Patient remains on hydroxychloroquine and will remain on it indefinitely. Patient had been on Prednisone in the past, but discontinued due to negative response. Will begin immunosuppressant infusions soon to treat nephritis. Various medications are used to manage pain, insomnia, tachycardia, depressions, Hashimoto’s, and migraines.6. What is your prognosis for this patient? Patient’s battle with lupus will be lifelong, and measures to manage lupus symptoms must be ongoing in an effort to prolong life and attain a better quality of life. Working has proven to be too stressful and would likely worsen her condition. She will need to be monitored throughout life to control the various lupus symptoms and address issues with major organs as they arise. They patient’s many symptoms often limit her ability to participate in regular daily activities. Lupus is a lifelong disability, and she will need to remain under the care of several physicians in order to manage her disease. Limiting stress and exertion will also be critical in order to manage her life.7. Would you expect the patient’s disability or impairment to last one year or more, or has it already lasted one year?Yes X No _______8. Does the disability or impairment prevent the patient from standing for six to eight hours?Yes X No _______Can the patient stand at all, and if so for how long? Her legs are weak and painful. Standing for more than 10 minutes becomes difficult for patient.9. Does the disability or impairment prevent the patient from sitting upright for six to eight hours?Yes X No _______ Can the patient sit at all, and if so for how long? Due to the severe pain in her legs, being in any position for more than 10-15 minutes becomes painful. She indicates that she needs to change positions frequently and not stay in any position (other than reclined) for very long.10. If the patient cannot stand and/or sit for 6-8 hours, what is the reason? Joint and muscle pain from lupus and fibromyalgia.11. Does the disability or impairment require the patient to lie down during the day? Yes X No ________If the answer is yes please explain why: She suffers extreme fatigue, as well as pain, and at times cannot stay awake mid-day, sometimes sleeping for several hours. Resting also gives relief from the pain in her legs from sitting and standing. 12. How far can the patient walk without stopping? Patient reports having to rest or slow down after walking several hundred feet or perhaps a half short block.13. In pounds, how much weight can the patient lift and carry during an eight-hour period? X Less than 5 5-10 11-20 21-50 over 5014. In pounds, how much weight can the patient lift and carry regularly/daily? X Less than 5 5-10 11-20 21-50 over 5015. Does the patient’s disability or impairment prevent the him or her from performing certain motions such as lifting, pulling, holding objects, etc.? Yes, the patient reports weakness and pain in hands and arms, which makes these tasks challenging.16. Does the patient have any difficulty performing the motions below? Bending - yesSquatting - yesKneeling - yesTurning any parts of the body - yesPatient is unable to bend, squat, kneel, climb stairs and even has to turn over carefully in bed due to pain and limitations of movement in legs and knees.17. Would the patient’s disability or impairment prevent him or her from traveling alone? Yes X No Why? Pain and weakness in arms or legs preclude her driving any distance. She needs assistance flying anywhere as well - cannot walk through the airport and needs wheelchair, unable to carry luggage.18. Are there any other factors not addressed in the above questions that you believe may affect the patient’s ability to work, or function normally in daily life? In general, the unpredictability and severity of the patient’s many lupus and fibromyalgia symptoms preclude her ability to perform responsibly and effectively in the workplace. Every day brings different challenges for this patient, challenges that make it impossible to be a reliable, productive employee. I fully support and recommend that she leave the workplace and apply for disability.19. If the patient has any complaints of pain, please address the following questions:What is nature of the pain?Joint and muscle painHow frequent is the pain?At all times.Level of pain?Moderate to severe (7-10)How would you rate the patient’s creditability with regards to claims of pain? Very credibleIs there an objective medical reason for the pain? Lupus and fibromyalgia20. Given your experience with the patient, your diagnosis, and the patient’s disability or impairment, do you believe he or she could continue or resume work at current or previous employment?Yes_______ No X If not, please explain why: Patient has reported numerous times that working had become increasingly difficult due to extreme fatigue, brain fog, poor concentration and sever pain. Patient also reported that driving for more than 15-20 minutes is difficult due to pain in arms and legs. She has mentioned many times how hard it was to continue working.Is there other work the patient could do given his or her skills and disability or impairment? No.22. How would you expect the patient’s diagnosis/disability to change over time? X Disability is Not Likely to Change Disability is TemporaryDate Report Completed:__________________________________________________Signature of Physician:___________________________________________________Physician Name:_________________________________________________________ Address:________________________________________________________________Telephone:______________________________________________________________Specialty:_______________________________________________________________

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