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Functional Limitations Degree of Limitation Restrictions of Activities of Daily Living None D Mild D Moderate D Marked D Extreme D Difficulties in maintaining Social Functioning None D Mild D Moderate D Marked D Extreme D Difficulties in maintaining Concentration, Persistence, and/or Pace None D Mild D Moderate D Marked D Extreme D Repeated episodes of decompensation in work or work like settings, each of an extended duration None D Mild D Moderate D Marked D Extreme D

Physical Capacities Less than 2 hours At least 2 hours About 6 hours Sit Stand Walk

Check the heaviest weight the patient can lift/carry: D Less than 10 lbs D10 lbs D20 lbs D 25 lbs D 50 lbs D100 lbs D more than 100 lbs Check the weight the patient can lift/carry frequently: D 10 lbs D25 lbs D 50 lbs D more than 50 lbs

Evaluation: Based upon your evaluation, has your patient’s medical condition lasted, or can it be expected to last, at least 12 months? Yes D No D Is the patient’s medical condition expected to result in death? Yes D No D Does the patient’s medical condition prevent him/her from working? Yes D No D If yes, please give the duration: Day Month Year to Day Month Year

Remarks: (Please provide any additional information clarifying how the patient’s condition limits his or her ability to work. If possible, include a description of any restrictions in Activities of Daily Living, and/or Social Functioning, and/or Concentration, Persistence, and/or Pace due to the patient’s condition):

Please attach records or other additional medical or mental health evidence.

Signature of Medical Provider Printed Name of Medical Provider Date

(proposed rev. 08/04)