Form HA-1151 Medical Source Statement of Ability to Do Work-Related A

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

Form Approved
OMB NO.0960-0662

MEDICAL SOURCE STATEMENT OF
ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)
==================================================================================
SOCIAL SECURITY NUMBER
XXX-XX-XXXX

NAME OF INDIVIDUAL

To determine this individual's ability to do work-related activities oil a regular and continuous basis. please give us your
opinion for each activity shown below:
The following terms are defined as:
•

REGliLAR AND CONTINliOliS 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.

•

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

•

CONTINUOliSLY means more than two-thirds of the time.

Age and body habitus of the individual should not be considered in the assessment oflimitations. 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.
L

LIFTING/CARRYING
Check the boxes representing the amount the individual can lift and how often it can be lifted.
Lift

Never

Occasionally Frequently Continuously
(over 2/3)
(UD to 1/3) 1(1/3 to 2/3)

A. Up to 10 Ibs:
B. II to 20 Ibs:
C. 21 to 50 Ibs:

D. 51 to 100 Ibs:

Check the boxes representing the amount the individual can 9!!IY and how often it can be carried.
Carry

Never

Occasionally Frequently Continuously
(up to 1/3) I(1/3 to 2/3) (over 2/3)

A. Up to 10 Ibs:
B. II to 20 Ibs:
C. 21 to 50 Ibs:

D. 51 to 100 Ibs:

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 assessmen t.

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MEDICAL SOURCE STATE\1ENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

II. SITTING/STANDlNGIWALKING
Please check how many hours the individual can (ifless than one hour. how many minutes):
At One Time without InternJQtion

Minutes

Hours

A. Sit

01

02

03

04

05

06

07

OS

B. Stand

01

02

03

04

05

06

07

Os

C. Walk

01

02

03

04

05

06

07

Os

Total in an 8 hour work dav
Minutes
A. Sit

Hours

01

02

03

04

05

06

07

Os

B. Stand

01

02

03

04

05

06

07

OS

C. Walk

01

02

03

04

05

06

07

Os

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 ofthe 8 hours?

Does the individual require the use of a cane to ambulate? DYes

D No

If the answer is "yes" please answer the following:
•

How far can the individual ambulate without the use of a cane? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

•

Is the use of a eane medically necessary?

•

With a eane, can the individual use hislher free hand to earry small objects?

DYes DNo
DYes

DNo

Identij)t 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.

FORM HA-I I51-BK (04-2009)
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ef (04-2009)

MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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III. llSE OF HANDS
Indicate how often the individual can perfonn the following activities:
ACTIVITY

Ri~ht Hand
Never Occasionally Frequently Continuously
(up to If3) (1/3 to 2/3) (over 2/3)

Left Hand
Never Occasionally Frequently Continuously
(up to 1/3) 1(1/3 to 213) (over 2f3)

REACHING
(Overhead)
REACHING
(All Other)
HANDLING
FINGERING

=i

FEELING
PUSHIPULL

Which is the individual's dominant hand?

0

Right Hand

o Left Hand

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.

IV. USE OF FEET
Indicate how often the individual can perfonn the following activities:
ACTIVITY

Ri ht Foot
Never Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

Left Foot
Never Occasionally Frequently Continuously
(up to 113) (1/3 to 213) (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.

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MEDICAL SOURCE STATEMENT OF ABILITV TO DO WORK-RELATED ACTIVITIES (PHVSICAL)
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V. POSTliRAL 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 ANV OF THE IMPAIRMENTS AFFECT THE INDIVfJ)lr" HEARING OR VISION?
DNo

DYes

Not Evaluated

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

I. 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? D Yes
No
b. Can the individual use a telephone to communicate? DYes D No

2. If a visual impairment is present,
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? DYes D No

b. Is the individual able to read very small print?
c.

DYes

Is the individual able to read ordinary newspaper or book print?

d. Is the individual able to view a computer screen?

DYes

DNo
DYes

No

DNo

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

screws, nuts or bolts?
Yes
0 No

IdentifY the particular medical or clinical tindings (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.

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MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)
VII. El'Ii-VIRONMENTAL LIMITATIONS
How often can the individual tolerate exposure to the following conditions?
Condition

Never

Occasionally
(up to 1/3)

Frequently
(1/3 to 213)

Continuously
(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
Others:
(Identity)

Condition

Quiet
(Library)

Moderate
(Offiee)

Loud
(Heavy
Traffic)

Very Loud
(Jackhammer)

Noise
JdentiJY 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.

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MEDICAL SOlJRCE STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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VIII. PLEASE PLACE A CIIECK IN APPROPRIATE BOXES BASED SOLELY ON THE fNl)~'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 sinJl.le hand rail?
Can the individual prepare a simple meal & feed
himself/herself?
Can the individual care for their personal hygiene?
i

Can the individual sort, handle, or use paper/tiles?
Please identify the medical findings that support this assessment and why the finding 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 LIMIT ATIONS ABOVE ARE ASSUMED TO BE YOUR OPINION REGARDING CURRENT
LIMITATIONS ONLV.
HOWEVER, If' VOll HAVE SllFFICIENT INFORMATION TO FORM AN OPINION WITIIIN A
REASONABLE DEGREE OF MEDICAL PROBABILITY AS TO PAST LIMITATIONS, ON WHAT DATE
WERE THE LIMIT ATIONS VOll FOUND ABOVE FIRST PRESENT? _ _ _ _ _ __

XI. HAVE THE LIMITATIONS YOl) FOUND ABOVE LASTED OR WILL THEY LAST FOR
12 CONSECUTIVE MONTHS?
0 Yes 0 No

SIGNATURE

Print Name, Title and Medical Specialty (Legibly Please)

FORM HA-1151-BK (04-2009) ef (04-2009)
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Privacy Act Statement

I.

2.

inform ion, and ur prog ams and
al Soci 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 under U. 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.
FORM IIA-t 151-BK (04-2009) ef(04-2009)
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SSA will insert the following revised Privacy Act Statement into tire form at its next scheduled
reprinting:
Privacy Act Statement
Medical Source Statement of Ability to do Work-Related Activities (Physical)
Sections 205(a),223(d), (I614(a)(3)(H)(1) and 1631 (d) (I ) ofthe Social Security Act, as
amended, authorize us to collect this information. We will use the information you provide to
determine your ability to perform (physical) work-related activities on a regular and continuous
basis.
The information you furnish on this form is voluntary. However, failure to provide all or part of
the information requested may affect our ability to provide an accurate assessment of the
individual's physical abilities and/or impairments for this claim.
We rarely use the information you provided on this form for any other purpose other than the
reasons explained above. 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:

I. To enable a third party or an agency to assist Social Security in establishing rights to
Medicare 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 the 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.
A complete list of routine uses for this information is available in System of Records Notice
entitled, Completed Determination Record-Continuing Disability Determinations, 60-0050. This
notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at http://www.socialsecurity.gov or at your local Social Security
office.

Papenvork 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. You can find your local Social Security
office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. 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.