MAJOR DYSFUNCTION OF JOINTS TREATING PHYSICIAN DATA SHEET Long form FOR REPRESENTATIVE USE ONLY REPRESENTATIVE S NAME AND ADDRESS REPRESENTATIVE S TELEPHONE REPRESENTATIVE S EMAIL PHYSICIAN S NAME AND ADDRESS PHYSICIAN S TELEPHONE PHYSICIAN S EMAIL PATIENT S TELEPHONE PATIENT S NAME AND ADDRESS PATIENT S EMAIL PATIENT S SSN LEVEL OF ADJUDICATION: Initial DDS Recon DDS TYPE OF CLAIM: Initial CDR Hearing Officer Title 2 DIB/DWB CDB Administrative Law Judge Appeals Council Title 16 DI DC Federal District Court Federal Appeals Court Dear Dr. We are pursuing the Social Security disability claim for the above-named individual (the patient ). We understand how valuable your time is, and this data sheet has been designed to allow you to provide medical information in an efficient and organized way. As a treating physician, your records and medical judgment are vital in arguing for a fair disability determination for the patient before the Social Security Administration (SSA). If you receive multiple data sheets, please disregard repetitive questions. Your medical specialty please: Note 1: This document will not have legal validity for Social Security disability determination purposes unless completed by a licensed medical doctor or osteopath. Note 2: This document only concerns joint dysfunction. Other impairments and limitations resulting from a combination of impairments should be considered separately. Note 3: Age, degree of general physical conditioning, sex, body habitus (i.e., natural body build, physique, constitution, size, and weight), insofar as they are unrelated to the patient s medical disorder and symptoms, should not be considered when assessing the functional severity of the impairment. Form 1.02 (2003)
Occasionally means very little up to 1/3 of an 8 hour workday. Frequently means 1/3 to 2/3 of an 8 hour workday. I. What is the medical impairment (rheumatoid arthritis, traumatic arthritis, osteoarthritis, etc.) causing joint dysfunction? II. Is there a history of chronic joint pain and stiffness? Yes No Unknown If Yes, when did the patient first complain to you of such symptoms? Please specify treatment (specific medications or other treatments): Response of pain and stiffness to treatment: Complete symptomatic relief Partial symptomatic relief No symptomatic relief III. Does the patient have gross anatomical deformity of any joint? If Yes, please check all that apply. Yes No Unknown A. Hands/Wrist. Ulnar deviation One or both hands? If Yes, degrees of deviation? Right hand Swan-neck deformity Left hand If Yes, which fingers? Right hand: Thumb 2 nd 3 rd 4 th 5 th Left hand: Thumb 2 nd 3 rd 4 th 5 th Boutonniere deformity If Yes, which fingers? Right hand: Thumb 2 nd 3 rd 4 th 5 th Left hand: Thumb 2 nd 3 rd 4 th 5 th Contracture If Yes, which fingers? Right hand: Thumb 2 nd 3 rd 4 th 5 th Left hand: Thumb 2 nd 3 rd 4 th 5 th Form 1.02 (2003) Page 2 of 14
Bony or fibrous ankylosis If Yes, which fingers? Right hand: Thumb 2 nd 3 rd 4 th 5 th Left hand: Thumb 2 nd 3 rd 4 th 5 th Instability If Yes, which fingers? Right hand: Thumb 2 nd 3 rd 4 th 5 th Left hand: Thumb 2 nd 3 rd 4 th 5 th Other (please specify) B. Elbows. If Yes, which fingers? Right hand: Thumb 2 nd 3 rd 4 th 5 th Left hand: Thumb 2 nd 3 rd 4 th 5 th Contracture Left Right Bony or fibrous ankylosis Left Right Instability Left Right Other (please specify) Left Right Right passive elbow range of motion (degrees flexion): Right Left passive elbow range of motion (degrees flexion): Left C. Shoulders. Contracture Left Right Bony or fibrous ankylosis Left Right Instability Left Right Other (please specify) Left Right Passive shoulder range of motion (degrees): Abduction Forward elevation (flexion) Left: Right: D. Hips. Contracture Left Right Bony or fibrous ankylosis Left Right Instability Left Right Other (please specify) Left Right Passive hip range of motion (degrees): Flexion External rotation Internal rotation Left: Right: Form 1.02 (2003) Page 3 of 14
E. Knees. Contracture Left Right Bony or fibrous ankylosis Left Right Instability Left Right Other (please specify) Left Right Passive knee range of motion (degrees) Left knee flexion: Right knee flexion: F. Ankles. Contracture Left Right Bony or fibrous ankylosis Left Right Instability Left Right Other (please specify) Left Right Passive ankle range of motion (degrees): Dorsiflexion Plantar flexion Left: Right: G. Are there imaging studies for involved joints? Yes No Unknown If Yes, please provide the following information. 1. Joint involved: Left Right Imaging used Imaging abnormalities Plain x-ray Joint space narrowing (state % narrowing ) CT Bony ankylosis Fibrous ankylosis MRI Bone destruction Other (describe below) Form 1.02 (2003) Page 4 of 14
2. Joint involved: Left Right Imaging used Imaging abnormalities Plain x-ray Joint space narrowing (state % narrowing ) CT Bony ankylosis Fibrous ankylosis MRI Bone destruction Other (describe below) 3. Joint involved: Left Right Imaging used Imaging abnormalities Plain x-ray Joint space narrowing (state % narrowing ) CT Bony ankylosis Fibrous ankylosis MRI Bone destruction Other (describe below) H. Medications and doses 1. Please list medications and doses that the patient is taking. 2. Please describe significantly limiting drug side-effects (e.g., sleepiness, blurry vision, dizziness) which the patient has complained to you about and what steps were taken to minimize such symptoms. IV. The patient s current limitations and capacities. Note 1: The limiting effects of pain or other symptoms should be included in assessment of functional loss. Note 2: If the patient uses any type of orthotic or prosthetic device, questions pertain to function while using such devices. Form 1.02 (2003) Page 5 of 14
A. Lower extremity function. 1. Can the patient ambulate without the use of a hand-held assistive device that limits the functioning of both upper extremities? Yes No Unknown 2. Can the patient sustain a reasonable walking pace over a sufficient distance to be able to carry out activities of daily living? Yes No Unknown For example: Does the patient have the ability to travel without companion assistance to and from work or school? Yes No Unknown Does the patient require bilateral upper limb assistive devices, such as two crutches, two canes, or a walker? Yes No Unknown Is the patient able to walk one block at a reasonable pace on rough or uneven surfaces? Yes No Unknown Is the patient able to use standard public transportation? Yes No Unknown Is the patient able to carry out routine ambulatory activities, such as shopping and banking? Yes No Unknown Is the patient able to climb a few steps at a reasonable pace using a single handrail? Yes No Unknown Other marked limitation (please specify) B. Upper extremity function. Does the patient have an extreme loss of function in both upper extremities, to the extent that the ability to perform fine and gross movements seriously interferes with the ability to independently initiate, sustain, or complete activities? Yes No Unknown For example: Is the patient able to prepare a meal and feed himself or herself? Yes No Unknown Is the patient able to take care of personal hygiene? Yes No Unknown Is the patient able to sort and handle papers or files? Yes No Unknown Is the patient able to place files in a file cabinet at or above waist level? Yes No Unknown Other marked limitation (please specify). Form 1.02 (2003) Page 6 of 14
C. Specific residual functional capacities and limitations. Note: The following questions apply only to patients at least 18 years of age. For younger children, please discuss any known limitations in age-appropriate activities in section V. 1. Does the patient have the ability to stand and/or walk 6 8 hours daily on a long term basis? Yes No Unknown If No, how long can the patient stand and/or walk (with normal breaks) in a 6 8 hour work day? 2. What maximum weight can the patient lift and/or carry occasionally (cumulatively not continuously)? Unknown Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. Other (lbs.) 3. What weight can the patient lift and/or carry frequently (cumulatively not continuously)? Unknown Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. or more Other (lbs.) 4. Work environment temperature restrictions. a. Aside from exertional considerations such as lifting and carrying, does the patient have restrictions against exposure to extreme heat or cold? Yes No Unknown If Yes, please define: Extreme heat (F ): Extreme cold (F ): Check the appropriate boxes: Concentrated exposure means 1/3 to 2/3 of 8 hour workday. Moderate exposure means very little up to 1/3 of 8 hour workday. Unlimited Avoid Concentrated Exposure Avoid Even Moderate Exposure Avoid All Exposure Extreme cold Extreme heat Form 1.02 (2003) Page 7 of 14
b. Would the patient s exertional capacities for lifting and carrying (as described in 2. and 3. above) be further reduced by work in extremely hot or cold environments? Yes No Unknown If Yes, please use the following scale to indicate lifting and carrying capacity in relation to work environment temperature on blank chart following the example. EXAMPLE ONLY Environmental Work Temperature (Degrees Fahrenheit) Patient Can Lift (Pounds) O/F 100 and over N 95 100 N 90 95 N 85 90 10/5 80 85 20/10 75 80 20/10 70 75 50/25 65 70 50/25 60 65 20/10 55 60 20/10 50 55 20/10 45 50 10/5 40 45 10/5 35 40 N 30 35 N 25 30 N 20 25 N 15 20 N 10 15 N 5 10 N 0 and below N N = no exposure O = weight to be occasionally lifted F = weight to be frequently lifted FOR PHYSICIAN TO COMPLETE Environmental Work Temperature (Degrees Fahrenheit) 100 and over 95 100 90 95 85 90 80 85 75 80 70 75 65 70 60 65 55 60 50 55 45 50 40 45 35 40 30 35 25 30 20 25 15 20 10 15 5 10 0 and below N = no exposure O = weight to be occasionally lifted F = weight to be frequently lifted Patient Can Lift (Pounds) O/F 5. Specific types of function. a. Can the following activities be performed while not lifting or carrying the amount of weight specified previously for given temperature conditions, or not applying equivalent force? Pushing or pulling: Right arm: never occasionally frequently Unknown Left arm: never occasionally frequently Unknown Climbing: Smooth inclines: never occasionally frequently Unknown Rough inclines: never occasionally frequently Unknown Ladders: never occasionally frequently Unknown Poles: never occasionally frequently Unknown Stairs: never occasionally frequently Unknown Overhead work: Right arm: never occasionally frequently Unknown Left arm: never occasionally frequently Unknown Form 1.02 (2003) Page 8 of 14
Hand controls: Right hand: never occasionally frequently Unknown Left hand: never occasionally frequently Unknown Leg controls: (repetitive force must be applied with leg) Right leg: never occasionally frequently Unknown Left leg: never occasionally frequently Unknown Squatting: never occasionally frequently Unknown Kneeling: never occasionally frequently Unknown Crawling: never occasionally frequently Unknown Crouching: never occasionally frequently Unknown b. Can the following activities be performed while lifting or carrying the amount of weight specified previously for given temperature conditions, or while applying equivalent force Pushing or pulling: Right arm: never occasionally frequently Unknown Left arm: never occasionally frequently Unknown Climbing: Smooth inclines: never occasionally frequently Unknown Rough inclines: never occasionally frequently Unknown Ladders: never occasionally frequently Unknown Poles: never occasionally frequently Unknown Stairs: never occasionally frequently Unknown Overhead work: Right arm: never occasionally frequently Unknown Left arm: never occasionally frequently Unknown Hand controls: Right hand: never occasionally frequently Unknown Left hand: never occasionally frequently Unknown Leg controls: (repetitive force must be applied with leg) Right leg: never occasionally frequently Unknown Left leg: never occasionally frequently Unknown Squatting: never occasionally frequently Unknown Kneeling: never occasionally frequently Unknown Crawling: never occasionally frequently Unknown Crouching: never occasionally frequently Unknown 6. Does the claimant have impairment in balance as a result of lower extremity disease, injury, or reconstructive surgery? Yes No Unknown 7. Fine manipulatory ability. Does the patient have limitations in the ability to perform fine manipulations (precise, coordinated, reasonably rapid use of the fingers)? Yes No Unknown Form 1.02 (2003) Page 9 of 14
If Yes, please answer the following questions. a. Can the patient perform finger-thumb apposition at a normal speed? Yes No Unknown If No, please indicate all that apply: Poor coordination Left fingers Right fingers weakness Left fingers Right fingers finger ankylosis Left fingers Thumb 2 nd 3 rd 4 th 5 th Right fingers Thumb 2 nd 3 rd 4 th 5 th finger contracture Left fingers Thumb 2 nd 3 rd 4 th 5 th Right fingers Thumb 2 nd 3 rd 4 th 5 th slowness Left fingers Right fingers myotonic dystrophy Left fingers Right fingers left finger amputation Thumb MP PIP DIP 2 nd MP PIP DIP 3 rd MP PIP DIP 4 th MP PIP DIP 5 th MP PIP DIP right finger amputation Thumb MP PIP DIP 2 nd MP PIP DIP 3 rd MP PIP DIP 4 th MP PIP DIP 5 th MP PIP DIP b. In regard to hand function, could the patient perform the following activities at normal pace? Handle coins, including picking up coins from a flat surface? Right hand: Yes No Unknown Left hand: Yes No Unknown Dress oneself, including use of zippers and buttons? Right hand: Yes No Unknown Left hand: Yes No Unknown Write legibly? Yes No Unknown Use a computer keyboard or typewriter? Right hand: Yes No Unknown Left hand: Yes No Unknown Use a hand calculator? Right hand: Yes No Unknown Left hand: Yes No Unknown Form 1.02 (2003) Page 10 of 14
Handle small parts, as in electronic assembly? Right hand: Yes No Unknown Left hand: Yes No Unknown If No, please specify what diameter parts the patient could handle: Left hand: Right hand: Perform coordinated rolling movements with the fingers? Right hand: Yes No Unknown Left hand: Yes No Unknown Use a screwdriver, including positioning small screws in holes? Right hand: Yes No Unknown Left hand: Yes No Unknown Manipulate cloth and sewing thread? Yes No Unknown Form 1.02 (2003) Page 11 of 14
V. For children under age 18 only. Note: The limiting effects of pain or other symptoms should be included in assessment of functional loss. Does the child have significant limitations in age-appropriate activities? Yes No Unknown If Yes, specify the age-appropriate limitations of which you are aware, citing specific developmental test results where possible. Form 1.02 (2003) Page 12 of 14
VI. Additional Physician Comments. (Also list other disorders of which you are aware.) Physician s Name (print or type) Physician s Signature (no name stamps) Date Form 1.02 (2003) Page 13 of 14
VII. Representative Notes. Form 1.02 (2003) Page 14 of 14