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.

VIII. PLEASE PLACE A CHECK IN APPROPRIATE BOXES BASED SOLELY ON THE CLAIMANT'S PHYSICAL IMPAIRMENTS

ACTIVITY

YES NO

Can the individual perform activities like shopping?

Can the individual travel without a companion for assistance?

Can the individual ambulate without using a wheelchair, walker, or 2 canes or 2 crutches?

Can the individual walk a block at a reasonable pace on rough or uneven surfaces?

Can the individual use standard public transportation?

Can the individual climb a few steps at a reasonable pace with the use of a single hand rail?

Can the individual prepare a simple meal & feed himself/herself?

Can the individual care for their personal hygiene?

Can the individual sort, handle, or use paper/files?

Please identify the medical findings that support this assessment and why the findings support the assessment (unless a narrative report is attached).

IX. STATE ANY OTHER WORK-RELATED ACTIVITIES, WHICH ARE AFFECTED BY ANY IMPAIRMENTS, AND INDICATE HOW THE ACTIVITIES ARE AFFECTED. WHAT ARE THE MEDICAL FINDINGS THAT SUPPORT THIS ASSESSMENT?

X.THE LIMITATIONS ABOVE ARE ASSUMED TO BE YOUR OPINION REGARDING CURRENT LIMITATIONS ONLY.

HOWEVER, IF YOU HAVE SUFFICIENT INFORMATION TO FORM AN OPINION WITHIN A REASONABLE DEGREE OF MEDICAL PROBABILITY AS TO PAST LIMITATIONS, ON WHAT DATE WERE THE LIMITATIONS YOU FOUND ABOVE FIRST PRESENT?

XI. HAVE THE LIMITATIONS YOU FOUND ABOVE LASTED OR WILL THEY LAST FOR

12 CONSECUTIVE MONTHS?

Yes

No

SIGNATURE

DATE

Print Name, Title and Medical Specialty (Legibly Please)

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act, as amended, authorize us to collect this information. The information you provide will be used to complete processing of the named patient's claim.

The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent an accurate or timely decision on the named patient's claim.

We rarely use the information you supply for any purpose other than for determining eligibility for benefits. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans' Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, state and local level; and

4.To facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, state or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line at www.ssa.gov or at your local Social Security office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. SEND OR

BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed underU. S. Government agencies in your telephone directory or you may call Social Security at

1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore,MD 21235-6401. Send only comments relating to our time estimate to

this address, not the completed form.