Sleep Disorders Residual Functional Capacity Questionnaire

SLEEP DISORDERS RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE
To: Social Security Administration Re: __________________________________(Name of Patient)
__________________________________(Social Security No.)
Please answer the following questions concerning your patient's impairments. Attach all relevant treatment
notes, laboratory and test results which have not been provided previously to the Social Security
Administration.
1. Nature, frequency and length of contact: ________________________________________________

2. Diagnoses: _____________________________________________________________________
3. Identify the clinical findings and test results which support your diagnoses (e.g., multiple sleep latency test,
REM testing, EEG, polysomnographic studies, etc.):
____________________________________________________________________________
___________________________________________________________________________
4. Identify all of your patient’s symptoms, including:
__ Cataplectic attacks __ Sleep paralysis __ Fatigue
__ Hypnagogic phenomena __ Sleep attacks __ hypertension
__ Insomnia __ Personality change __ Sleep apnea
__ Obesity __ Chronic pulmonary __ Memory impairment
__ Disturbance in cognitive function __ Excessive daytime sleepiness
__ Other : _____________________________________________________________
5. For the above symptoms, estimate frequency and duration of each symptom _____________________
____________________________________________________________________________
6. Does your patient normally have signs just prior to a spell? ___Yes ___No
If yes, please describe typical signs: ___________________________________________________
_____________________________________________________________________________
7. Do certain situations (e.g., exertion, stress, fatigue, excitement) tend to trigger these spells? ___Yes
___No
If yes, please list these situations: __________________________________________________
____________________________________________________________________________
8. Does abuse of alcohol or drugs cause or contribute to your patient’s symptoms? ___Yes ___No
9. Do emotional factors contribute to the severity of your patient’s symptoms and functional limitations?
___Yes ___No
10. Are your patient’s impairments (physical impairments plus any emotional impairments) reasonably
consistent with the symptoms and limitations described in this evaluation? ___Yes ___No
If no, please explain:_____________________________________________________________
____________________________________________________________________________
11. Treatment and response, including list of medications prescribed and their side effects on your patient
(e.g., drowsiness, ataxia, nystagmus, etc.):
______________________________________________________
____________________________________________________________________________
12. Is your patient presently taking medications as prescribed? ___Yes ___No
13. Prognosis: _____________________________________________________________________
14. Have your patient’s impairments lasted or can they be expected to last at least 12 months? ___Yes
___No
15. Please check appropriate boxes below which describe the limitations from your patient’s impairments:
___ Should avoid work involving climbing and heights.

___ Should avoid power machines, moving machinery or other hazardous conditions.
___ Should limit or avoid operation of motor vehicles.
___ Should avoid work which is not closely supervised where a spell could occur in isolation.
___ Supervisors and/or co-workers must be trained for basic assistance.
___ May need breaks at unpredictable intervals during workday due to spells, adverse effects
of medications, etc.
___ Describe anticipated frequency and duration of breaks:__________________________
Exertional limitations:
___ Maximum lift/carry ______ pounds on an occasional basis.

___ Should avoid work that involves mainly standing and walking (as opposed to sitting)
throughout the workday.
Non-exertional limitations:
Indicate areas where your patient has serious limitations in performing the following activities in the
workplace on a sustained basis:
___ Understand, remember and carry out simple

instructions
___ Maintain attention for two hour segments
___ Be punctual within customary, usually strict tolerances
___ Sustain an ordinary routine without special supervision
___ Perform at a consistent pace
___ Deal with normal work stresses
___ Maintain socially appropriate behavior
___ Travel in unfamiliar places
___ Use public transportation
17. Are you patient’s impairments likely to produce “good days” and “bad days”? ___Yes ___No
If yes, please estimate, on the average, how often your patient is likely to be absent from work as a result
of the impairments or treatment:
___ Never ___ Less than once a month
___ About once a month ___ About twice a month
___ About three times a month ___ About four times a month
___ More than four times a month
18. Please describe any other limitations (such as limitations in the ability to sit, stand, walk, lift, bend, stoop,
limitations in using arms, hands, fingers, limited vision, difficulty hearing, need to avoid temperature
extremes, wetness, humidity, noise, dust, fumes, gases or hazards, etc.) that would affect your patient’s
ability to work at a regular job on a sustained basis:
____________________________________________________________________________
____________________________________________________________________________
19. What is the earliest date that the description of symptoms and limitations in this form applies? ________
________________________________________
_________________________________
Physician’s Signature Date form completed
Printed/Typed Name: __________________________________________
Address: __________________________________________
__________________________________________
__________________________________________
2 © COPYRIGHT M. Murburg (Rev 08/31/09)

Return form to:
Mike Murburg, PA
15501 N. Florida Ave
Tampa, FL 33613
Tel: 813-264-5363
Fax: 813-514-9788
3 © COPYRIGHT M. Murburg (Rev 08/31/09)

Sleep Disorders Residual Functional Capacity Questionnaire

Uploaded by

Copyright:

Available Formats

Sleep Disorders Residual Functional Capacity Questionnaire

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Sleep Disorders Residual Functional Capacity Questionnaire

Uploaded by

Copyright:

Available Formats

SLEEP DISORDERS RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE

To: Social Security Administration Re: __________________________________(Name of Patient)

__________________________________(Social Security No.)

1. Nature, frequency and length of contact: ________________________________________________

13. Prognosis: _____________________________________________________________________

___ Should avoid work involving climbing and heights.

_ Maximum lift/carry ____ pounds on an occasional basis.

___ Understand, remember and carry out simple

Printed/Typed Name: __________________________________________

2 © COPYRIGHT M. Murburg (Rev 08/31/09)

3 © COPYRIGHT M. Murburg (Rev 08/31/09)

You might also like