Form Ha 1151 Bk – Fill Out and Use This PDF

MEDICAL SOURCE STATEMET OF ABILITY TO DO WORKRELATED ACTIVITIES (PHYSICAL)

III.USE OF HADS

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IV. USE OF FEET

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FORM HA1151BK (042009) ef (042009)

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MEDICAL SOURCE STATEMET OF ABILITY TO DO WORKRELATED ACTIVITIES (PHYSICAL)

V.POSTURAL ACTIVITIES

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VI. DO AY OF THE IMPAIRMETS AFFECT THE IDIVIDUAL’S HEARIG OR VISIO?

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FORM HA1151BK (042009) ef (042009)

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MEDICAL SOURCE STATEMET OF ABILITY TO DO WORKRELATED ACTIVITIES (PHYSICAL)

VII. EVIROMETAL LIMITATIOS

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MEDICAL SOURCE STATEMET OF ABILITY TO DO WORKRELATED ACTIVITIES (PHYSICAL)

VIII. PLEASE PLACE A CHECK I APPROPRIATE BOXES BASED SOLELY O THE IDIVIDUAL’S PHYSICAL IMPAIRMETS

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IX. STATE AY OTHER WORKRELATED ACTIVITIES, WHICH ARE AFFECTED BY AY IMPAIRMETS, AD IDICATE HOW THE ACTIVITIES ARE AFFECTED. WHAT ARE THE MEDICAL FIDIGS THAT SUPPORT THIS ASSESSMET?

X.THE LIMITATIOS ABOVE ARE ASSUMED TO BE YOUR OPIIO REGARDIG CURRET LIMITATIOS OLY.

HOWEVER, IF YOU HAVE SUFFICIET IFORMATIO TO FORM A OPIIO WITHI A REASOABLE DEGREE OF MEDICAL PROBABILITY AS TO PAST LIMITATIOS, O WHAT DATE WERE THE LIMITATIOS YOU FOUD ABOVE FIRST PRESET? __________________

XI. HAVE THE LIMITATIOS YOU FOUD ABOVE LASTED OR WILL THEY LAST FOR
12 COSECUTIVE MOTHS?		Yes	o
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FORM HA1151BK (042009) ef (042009)
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Privacy Act Statement

Medical Source Statement of Ability to do WorkRelated Activities (Physical)

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#+!SE!D OR BRI!G THE COMPLETED FORM TO

YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1800 7721213 (TTY 18003250778). /

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