Ha 1151 Form – Fill Out and Use This PDF

SOCIAL SECURITY ADMINISTRATION	Form Approved
OFFICE OF DISABILITY ADJUDICATION AND REVIEW	OMB No. 0960-0662

MEDICAL SOURCE STATEMENT OF

ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

NAME OF INDIVIDUAL	SOCIAL SECURITY NUMBER
	- -

To determine this individual's ability to do work-related activities on a regular and continuous basis, please give us your opinions for each activity shown below:

The following terms are defined as:

.REGULAR AND CONTINUOUS BASIS means 8 hours a day, for 5 days a week, or an equivalent work schedule.

.OCCASIONALLY means very little to one-third of the time.

.FREQUENTLY means from one-third to two-thirds of the time.

.CONTINUOUSLY means more than two-thirds of the time.

Age and body habitus of the individual should not be considered in the assessment of limitations. It is important that you relate particular medical or clinical findings to any assessed limitations in capacity: The usefulness of your assessment depends on the extent to which you do this.

I.LIFTING/CARRYING

Check the boxes representing the amount the individual can lift and how often it can be lifted.

Lift	Never Occasionally	Frequently	Continuously
	(up to 1/3)	(1/3 to 2/3)	(over 2/3)
A. Up to 10 lbs:
B. 11 to 20 lbs:
C. 21 to 50 lbs:
D. 51 to 100 lbs:

Check the boxes representing the amount the individual can carry and how often it can be carried.

Carry	Never	Occasionally	Frequently	Continuously
		(up to 1/3)	(1/3 to 2/3)	(over 2/3)
A. Up to 10 lbs:
B. 11 to 20 lbs:
C. 21 to 50 lbs:
D. 51 to 100 lbs:

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings support the assessment.

II. SITTING/STANDING/WALKING

Please check how many hours the individual can (if less than one hour, how many minutes):

If the total time for sitting, standing and walking does not equal or exceed 8 hours, what activity is the individual performing for the rest of the 8 hours?

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain etc.) which support your assessment or any limitations and why the findings support the assessment.

III.USE OF HANDS

Indicate how often the individual can perform the following activites:

ACTIVITY		Right Hand					Left Hand
	Never	Occasionally	Frequently	Continuously		Never	Occasionally	Frequently	Continuously
		(up to 1/3)	(1/3 to 2/3)	(over 2/3)			(up to 1/3)	(1/3 to 2/3)	(over 2/3)
REACHING
(Overhead)
REACHING
(All Other)
HANDLING
FINGERING
FEELING
PUSH/PULL

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings support this assessment.

IV. USE OF FEET

Indicate how often the individual can perform the following activities:

ACTIVITY		Right Foot					Left Foot
	Never	Occasionally	Frequently	Continuously		Never	Occasionally	Frequently	Continuously
		(up to 1/3)	(1/3 to 2/3)	(over 2/3)			(up to 1/3)	(1/3 to 2/3)	(over 2/3)
Operation of
Foot Controls

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings support the assessment.

V. POSTURAL ACTIVITIES

How often can the individual perform the following activities:

ACTIVITY	Never	Occasionally	Frequently	Continuously
		(up to 1/3)	(1/3 to 2/3)	(over 2/3)
Climb stairs and ramps
Climb ladders or scaffolds
Balance
Stoop
Kneel
Crouch
Crawl

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain etc.) which support your assessment or any limitations and why the findings support the assessment.

VI. DO ANY OF THE IMPAIRMENTS AFFECT THE CLAIMANT'S HEARING OR VISION?

If "yes" please complete the following questions (where appropriate)

1.If a hearing impairment is present,

a. Does the individual retain the ability to hear and understand simple oral instructions and

to communicate simple information?

Yes

No

a. Is the individual able to avoid ordinary hazards in the workplace, such as boxes on the

floor, doors ajar, or approaching people or vehicles?

Yes

No

e. Is the individual able to determine differences in shape and color of small objects such as

screws, nuts or bolts?

Yes

No

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain etc.) which support your assessment or any limitations and why the findings support the assessment.

VII. ENVIRONMENTAL LIMITATIONS

How often can the individual tolerate exposure to the following conditions:

	Condition	Never		Occasionally			Frequently		Continuously
				(up to 1/3)			(1/3 to 2/3)		(over 2/3)
	Unprotected
	Heights
	Moving
	Mechanical
	Parts
	Operating a
	motor vehicle
	Humidity
	and wetness
	Dust, odors,
	fumes and
	pulmonary
	irritants
	Extreme cold
	Extreme heat
	Vibrations
	Other:
	(Identify)
		Quiet			Moderate		Loud	Very Loud
	Condition	(Library)			(Office)		(Heavy	(Jackhammer)
							Traffic)
	Noise

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results, history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings support the assessment.