Form Physical Capacity PDF Details

The Physical Capacity form, officially known as Form SSA-4734-BK, is a comprehensive document utilized by the Social Security Administration to assess an individual's residual functional capacity due to physical impairments. Essential for individuals submitting claims for disability benefits, this form encompasses a detailed evaluation across various domains including exertional, postural, manipulative, visual, communicative, and environmental limitations. Medical professionals are required to base their conclusions on a holistic consideration of evidence within the claimant's file, which includes clinical and laboratory findings, symptom reports, daily activity accounts, and more. The form not only seeks to establish the degree of an individual's physical limitations but also to document the impact of these limitations on their ability to perform work-related activities. By meticulously guiding the assessor through each section from A to F, the form ensures a reasoned judgment reflecting the claimant's ability to engage in work within their physical capacities, underscoring the importance of specific, evidence-based conclusions for each assessed category.

QuestionAnswer
Form NameForm Physical Capacity
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesfunctional capacity assessment pdf, physical capacity assessment, physical functional assessment, ssa 4734 bk

Form Preview Example

Form SSA-4734-BK (08-2017)

 

Discontinue Prior Editions

 

Social Security Administration

Page 1 of 7

PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT

 

CLAIMANT:

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBERHOLDER (IF CDB OR DWB CLAIM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIMARY DIAGNOSIS:

RFC ASSESSMENT IS FOR:

Date 12 Months After Onset

 

 

 

 

 

 

 

 

 

 

Current Evaluation

(Date)

 

SECONDARY DIAGNOSIS:

 

Date Last Insured

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER ALLEGED IMPAIRMENTS:

Other (Specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER ALLEGED IMPAIRMENTS CONTINUED:

 

 

 

 

 

 

 

1. LIMITATIONS:

For Each Section A - F

Base your conclusions on all evidence in file (clinical and laboratory findings, symptoms, observations, lay evidence, reports of daily activities, etc.).

Check the blocks which reflect your reasoned judgment.

Describe how the evidence substantiates your conclusions (Cite specific clinical and laboratory findings, observations, lay evidence, etc.).

Ensure that you have:

•Requested appropriate medical opinions (DI 22505.000ff. and DI 22510.000ff.) and that you have given appropriate consideration to medical opinions (See Section 3.).

•Considered and responded to any alleged limitations imposed by symptoms (pain, fatigue, etc.) attributable, in your judgment, to a medically determinable impairment. Discuss your assessment of symptom-related limitations in the explanation for your conclusions in A - F below (See also Section 2.).

•Responded to all allegations of physical limitations or factors which can cause physical limitations.

Frequently means occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous). Occasionally means occurring from very little up to one-third of an 8-hour workday

(cumulative, not continuous).

Form SSA-4734-BK (08-2017)

Page 2 of 7

 

 

A. EXERTIONAL LIMITATIONS

 

None established. (Proceed to section B.)

 

1.Occasionally lift and/or carry (including upward pulling) (maximum) - when less than one-third of the time or less than 10 pounds, explain the amount (time/pounds) in item 6.

less than 10 pounds 10 pounds

20 pounds

50 pounds

100 pounds or more

2.Frequently lift and/or carry (including upward pulling) (maximum) - when less than two-thirds of the time or less than 10 pounds, explain the amount (time/pounds) in item 6.

less than 10 pounds

10 pounds

25 pounds

50 pounds or more

3.Stand and/or walk (with normal breaks) for a total of -

less than 2 hours in an 8-hour workday

at least 2 hours in an 8-hour workday

about 6 hours in an 8-hour workday

medically required hand-held assistive device is necessary for ambulation

4.Sit (with normal breaks) for a total of -

less than about 6 hours in an 8-hour workday about 6 hours in an 8-hour workday

must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in item 6.) 5. Push and/or pull (including operation of hand and/or foot controls) -

unlimited, other than as shown for lift and/or carry limited in upper extremities (describe nature and degree) limited in lower extremities (describe nature and degree)

6.Explain how and why the evidence supports your conclusions in items 1 through 5. Cite the specific facts upon which your conclusions are based.

Form SSA-4734-BK (08-2017)

Page 3 of 7

 

 

B. POSTURAL LIMITATIONS

None established. (Proceed to section C.)

Frequently

Occasionally

Never

1. Climbing - ramp/stairs

- ladder/rope/scaffolds

2. Balancing

3. Stooping

4. Kneeling

5. Crouching

6. Crawling

7.When less than two-thirds of the time for frequently or less than one-third for occasionally, fully describe and explain. Also, explain how and why the evidence supports your conclusions in items 1 through 6. Cite the specific facts upon which your conclusions are based.

C. MANIPULATIVE LIMITATIONS

 

 

None established. (Proceed to section D.)

LIMITED

UNLIMITED

 

1. Reaching all directions (including overhead)

2. Handling (gross manipulation)

3. Fingering (fine manipulation)

4. Feeling (skin receptors)

5.Describe how the activities checked "limited" are impaired. Also, explain how and why the evidence supports your conclusions in items 1 through 4. Cite the specific facts upon which your conclusions are based.

Form SSA-4734-BK (08-2017)

Page 4 of 7

D. VISUAL LIMITATIONS

None established. (Proceed to section E.)

LIMITED UNLIMITED

1. Near acuity

2. Far acuity

3. Depth perception

4. Accommodation

5. Color Vision

6. Field of vision

7.Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports your conclusions in items 1 through 6. Cite the specific facts upon which your conclusions are based.

E. COMMUNICATIVE LIMITATIONS

None established. (Proceed to section F.)

LIMITED UNLIMITED

1. Hearing

2. Speaking

3.Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports your conclusions in items 1 and 2. Cite the specific facts upon which your conclusions are based.

Form SSA-4734-BK (08-2017)

 

 

 

Page 5 of 7

 

 

 

 

 

F. ENVIRONMENTAL LIMITATIONS

 

AVOID

AVOID

 

 

 

AVOID ALL

None established. (Proceed to Section 2.)

 

CONCENTRATED

MODERATE

UNLIMITED

EXPOSURE

EXPOSURE

EXPOSURE

 

1. Extreme cold

 

 

 

 

2. Extreme heat

3. Wetness

4. Humidity

5. Noise

6. Vibration

7. Fumes, odors, dust, gases, poor ventilation, etc.

8. Hazards

(machinery, heights, etc.)

9.Describe how these environmental factors impair activities and identify hazards to be avoided. Also, explain how and why the evidence supports your conclusions in items 1 through 8. Cite the specific facts upon which your conclusions are based.

Form SSA-4734-BK (08-2017)

Page 6 of 7

 

 

2. SYMPTOMS:

For symptoms alleged by the claimant to produce physical limitations, and for which the following have not previously been addressed in Section 1, discuss whether:

A. The symptom(s) is attributable, in your judgment, to a medically determinable impairment.

B. The severity or duration of the symptom(s), in your judgment, is disproportionate to the expected severity or expected duration on the basis of the claimant's medically determinable impairment(s).

C. The severity of the symptom(s) and its alleged effect on function is consistent, in your judgment, with the total medical and nonmedical evidence, including statements by the claimant and others, observations regarding activities of daily living, and alterations of usual behavior or habits.

3.MEDICAL OPINION(S):

A.Is a medical opinion(s) in file?

Yes

B.If yes, is the medical opinion(s) significantly different from your findings?

No (Includes situations in which there was no medical source or when the medical source(s) did not provide a medical opinion).

Yes

No

C. If yes, explain why the medical opinion(s) is not consistent with or supported by the evidence in file. Cite the medical source's name and the medical opinion date.

Form SSA-4734-BK (08-2017)

Page 7 of 7

4. ADDITIONAL COMMENTS:

 

5.SIGNATURE:

A. Signatory's Role

Medical Consultant (MC)

OR

Single Decisionmaker (SDM)

B. MC's Statement

The MC does not check this block when the MC's assessment is preliminary, advisory or partial.

THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION.

SIGNATURE:

MEDICAL CONSULTANT'S CODE:

DATE:

 

 

 

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Pay close attention while filling out this pdf. Make certain every blank field is filled in correctly.

1. Fill out the ssdi forms for doctors with a number of essential blanks. Gather all the necessary information and make sure not a single thing overlooked!

Stage no. 1 for submitting residual functional capacity form pdf

2. Once your current task is complete, take the next step – fill out all of these fields - A EXERTIONAL LIMITATIONS, None established Proceed to, Occasionally lift andor carry, less than pounds, pounds, pounds, pounds pounds or more, Frequently lift andor carry, less than pounds, pounds, pounds, pounds or more, Stand andor walk with normal, less than hours in an hour workday, and at least hours in an hour workday with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

A way to prepare residual functional capacity form pdf part 2

3. The following section is mostly about at least hours in an hour workday, about hours in an hour workday, medically required handheld, Sit with normal breaks for a, less than about hours in an hour, about hours in an hour workday, must periodically alternate, Push andor pull including, unlimited other than as shown for, limited in upper extremities, limited in lower extremities, and Explain how and why the evidence - complete each one of these empty form fields.

Filling out section 3 of residual functional capacity form pdf

4. To move onward, this next stage will require filling out a few fields. These comprise of Frequently, Occasionally, Never, B POSTURAL LIMITATIONS, None established Proceed to, Climbing rampstairs, ladderropescaffolds, Balancing, Stooping, Kneeling, Crouching, Crawling, and When less than twothirds of the, which you'll find key to continuing with this particular form.

residual functional capacity form pdf writing process explained (step 4)

People who work with this PDF generally make errors while filling out When less than twothirds of the in this part. Make sure you reread everything you type in right here.

5. Since you draw near to the last parts of your form, there are a few extra requirements that need to be fulfilled. Mainly, C MANIPULATIVE LIMITATIONS, None established Proceed to, Reaching all directions including, Handling gross manipulation, Fingering fine manipulation, Feeling skin receptors, LIMITED, UNLIMITED, and Describe how the activities must be done.

Completing section 5 in residual functional capacity form pdf

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