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When filing for Disability with the Social Security Administration, print this form, take it to your Physician and have it filled out.  If you have retained the services of a Disability Attorney, please discuss this form BEFORE mailing it to SSA.


Fibromyalgia Medical Evaluation Form

 

To: _______________________________________________________

Fibromyalgia Medical Evaluation

Patients Name

__________________________________________________________

Social Security Number and/or Claim Number

_________________________________

Please answer the following questions concerning your patient's impairments:

1. Nature, frequency, and length of contact:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

2. Does your patient meet the American Rheumatological criteria for Fibromyalgia?

Yes ___ No ___

3. List any other diagnosed impairments:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

4. Prognosis:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

5. Have your patient's impairments lasted or can they be expected to last at least 12 months?

Yes ___ No ___

6. Identify the clinical findings, laboratory and test results which show your client's medical impairments:

7. Identify all of your patient's symptoms:

Multiple Tender Points ____ Numbness and Tingling ____
Non-restorative Sleep ____ Sicca Symptoms ____
Chronic Fatigue ____ Raynaud's Phenomenon ____
Morning Stiffness ____ Dysmenorrhea ____
Subjective Swelling ____ Anxiety ____
Irritable Bowel Syndrome ____ Panic Attacks ____
Depression ____ Frequent Severe Headaches ____
Mitral Valve Prolapse ____ Female Urethral Syndrome ____
Hypothyroidism ____ Premenstrual Syndrome ____
Vestibular Dysfunction ____ Carpal Tunnel Syndrome ____
Incoordination ____ Chronic Fatigue Syndrome ____
Cognitive Impairment ____ TMJ Dysfunction ____
Myofascial Pain Syndrome ____ Multiple Trigger Points ____

8. If your patient has pain:

a: Identify the location of pain, including, where appropriate, an indication of right or left side or bilateral areas affected:

Lumbosacral: Spine ___ Cervical Spine ___ Thoracic Spine ___ Chest ___
Shoulders: Right ___ Left ___ Bilateral ___  
Arms: Right ___ Left ___ Bilateral ___  
Hands/fingers: Right ___ Left ___ Bilateral ___  
Hips: Right ___ Left ___ Bilateral ___  
Leg: Right ___ Left ___ Bilateral ___  
Knees: Right ___ Left ___ Bilateral ___  
Ankles: Right ___ Left ___ Bilateral ___  
Feet: Right ___ Left ___ Bilateral ___  

b: Describe the nature, frequency, and severity of your patient's pain:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

c: Identify any factors that precipitate pain:

Changing weather ___ Fatigue ___
Movement/overuse ___ Stress ___
Hormonal Changes ___ Cold ___
Humidity ___ Heat ___
Allergy ___ Static position ___
Other _________________________________

9. Is your patient a malingerer?

Yes ___ No ___

10. Do emotional factors contribute to the severity of your patient's symptoms and functional limitations?

Yes ___ No ___

11. Are your patient's physical impairments plus any emotional impairments reasonably consistent with symptoms and functional limitations described in this evaluation:

Yes ___ No ___

12. How often is your patient's experience of pain sufficiently severe to interfere with attention and concentration?

Never ___
Seldom ___
Often ___
Frequently ___
Constantly ___

13. To what degree is your patient limited in the ability to deal with work stress?

No Limitation ___
Slight Limitation ___
Moderate Limitation ___
Marked Limitation ___
Severe Limitation ___

14. Identify the side effects of any medication which may have implications for working, e.g. dizziness, drowsiness, stomach upset, etc.

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

15. As a result of your patient's impairments, estimate your patient's functional limitations if your patient were placed in a competitive work situation:

a: How many city blocks can your patient walk without rest or severe pain?

Comment:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

b: How long can your patient continually sit, stand and walk at one time:

Sit Stand Walk  
___ ___ ___ Less than 2 hours
___ ___ ___ 3 hours
___ ___ ___ 4 hours
___ ___ ___ 5 hours
___ ___ ___ 6 hours

c: Does your patient need to include periods of walking during an 8 hour day?

Yes ___ No ___

d: Does your patient need a job which permits shifting positions at will from sitting, standing or walking?

Yes ___ No ___

e: Will your patient sometimes need to lie down at unpredictable intervals during a work shift?

Yes ___ No ___

f: With prolonged sitting, should your patient's legs be elevated?

Yes ___ No ___ Cannot tolerate prolonged sitting ___

g: While engaged in occasional standing/walking, must your patient use a cane or other assistive device?

Yes ___ No ___ Sometimes ___

h: How many pounds can your patient carry in a competitive work situation in an average workday?

    "Occasionally" means less than 1/3 of the workday.

    "Frequently" means between 1/3 and 2/3 of the workday.

  Never Occasionally Frequently
Less than 10 pounds ___ ___ ___
11 to 20 pounds ___ ___ ___
21 to 30 pounds ___ ___ ___
31 to 50 pounds ___ ___ ___

i: Does your patient have any significant limitations in:

Reaching Yes ___ No ___ Sometimes ___
Handling Yes ___ No ___ Sometimes ___
Fingering Yes ___ No ___ Sometimes ___

If yes, please indicate the percentage of time during a workday on a competitive job that your patient can use hands/fingers/arms for the following repetitive activities:

HANDS (grasp, turn, twist objects)

Right ___%  Left ___%

FINGERS (fine manipulation)

Right ___% Left ___%
ARMS (reaching - including overhead)
Right ___% Left ___%

j: Does your patient have the ability to bend and twist at the waist:

Not at all ___
Occasionally ___
Frequently ___


k: On the average, how often do you anticipate that your patient's impairments and treatments or treatment would cause the patient to be absent from work?

Never ___
Less than once a month ___
About once a month ___
About twice a month ___
About three times a month ___
More than three times a month ___

16. Please describe any other limitations that would affect this patient's ability to work at a regular job on a sustained basis:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

17. Does your patient have:

Headaches ___   Migraines ___
Morning Stiffness ___   Weakness ___
Shortness of Breath ___   Dizziness ___
Pelvic Pain ___   Nausea ___
Leg Cramps ___   Sciatica ___
Lack of Endurance ___   Anxiety ___
Buckling Ankles ___   Sleep Deprivation ___
Muscle Twitching ___   Fatigue ___
Problems Climbing Stairs ___   Reflux Esophagitis ___
Handwriting Difficulties ___   Cramps ___
Visual Perception problems ___   Confusional Status ___
Motor Coordination Problems ___   Mood Swings ___
Buckling Knees ___   Panic Attacks ___
Numbness/Tingling ___   Memory Impairment ___
Irritability ___   Speech Difficulties ___
Sensitivity to
Cold ___ Heat ___ Light ___ Humidity ___ Other ___

 

Date:  _______________________

Doctor Signature:

_________________________________________________________

Print/Type Name:

_________________________________________________________

Address:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
 


 


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All Rights Reserved. 
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Most recent revision Wednesday September 11, 2002