Physician Form

Download Physicians Opinion Form in Adobe PDF

Treating Physicians Opinion, Based Up on Objective Medical Findings, Of Patient’s
Residual Functional Capacity

Patient:
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SSN:
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Patient’s Symptoms:
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Patient’s Medical History:
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Findings of Most Recent Examination:

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Diagnoses:
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Treatment:
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In my medical opinion, out of an 8 hour work day this patient is able to (circle answers):

Standing at one time:
None   15 min   30 min   60 min   2 hrs   4 hrs

Sitting at one time:
None   15 min   30 min   60 min   2 hrs   4 hrs

Lifting on an occasional basis:
None   15 min   30 min   60 min   2 hrs   4 hrs

Lifting on a frequent basis:
None   15 min   30 min   60 min   2 hrs   4 hrs

Bending:
Never   Occasionally   Frequently   Constantly

Stooping:
Never   Occasionally   Frequently   Constantly

Balancing:
Never   Occasionally   Frequently   Constantly

Manipulation of Right Hand:
Never   Occasionally   Frequently   Constantly

Manipulation of Left Hand:
Never   Occasionally   Frequently   Constantly

Raising Left Arm over Shoulder Level:
Never   Occasionally   Frequently   Constantly

Raising Right Arm over Shoulder Level:
Never   Occasionally   Frequently   Constantly

Need to elevate legs during 8 hour workday:
Never   Occasionally   Frequently   Constantly

Number of days of work per month that patient would likely miss due to impairments:
None   One   Two   More   than two

In my opinion, the patient suffers from pain that is:
None   Mild   Moderate   Severe   Extreme

Estimated date that these limitations began:

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Comments:

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Date: _________________________________________________________

 

Medical Provider Signature

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Medical Provider Name Printed

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 Download Physicians Opinion Form in Adobe PDF