Social Security's hearing-level form for a medical source's opinion of what a claimant can still do physically on a regular and continuous basis, meaning 8 hours a day, 5 days a week. It arrives per case, usually after a denied claim is appealed, from a hearing office, the disability determination services or the claimant's representative, and becomes evidence for the SSDI or SSI hearing.
A treating or examining physician or other medical source completes the entire seven-page form, including the findings behind each rating, and signs under penalty of perjury with printed name, title and medical specialty. The claimant has no section to fill in.
Two grids, one for lifting and one for carrying, with rows for up to 10 lbs, 11 to 20, 21 to 50 and 51 to 100 lbs, each rated never, occasionally (up to 1/3), frequently (1/3 to 2/3) or continuously (over 2/3). Below the grids, name the exam, imaging, lab, history or pain findings that support the ratings and explain why.
For sit, stand and walk, check how long the individual can do each at one time without interruption and the total in an 8-hour workday, in minutes if under one hour. If the totals don't reach 8 hours, say what the individual does for the rest. Cane questions follow: whether one is required, how far the person walks without it, whether it is medically necessary, and whether the free hand can carry small objects.
Rate the right and left hands separately for reaching overhead, reaching in all other directions, handling, fingering, feeling and push/pull, from never to continuously, then mark the dominant hand. Add the supporting findings (physical exam, x-ray, laboratory results, history and symptoms including pain) and connect each one to the limit it explains.
Rate operation of foot controls for the right and left foot separately on the same never to continuously scale, then give the findings that support any limitation. This section is short, but it still needs its own findings box completed if you mark anything less than continuously.
Rate how often the individual can climb stairs and ramps, climb ladders or scaffolds, balance, stoop, kneel, crouch and crawl, on the same never, occasionally, frequently or continuously scale. Then identify the particular medical or clinical findings behind the ratings, such as exam results, imaging or reported pain, and explain why they support them.
Answer whether any impairment affects hearing or vision: no, yes or not evaluated. If hearing is affected, say whether the individual can hear and understand simple oral instructions and use a telephone. If vision is affected, answer whether the individual can avoid ordinary workplace hazards, read very small and ordinary print, view a computer screen and tell the shape and color of small objects.
Rate tolerance for unprotected heights, moving mechanical parts, operating a motor vehicle, humidity and wetness, dust, odors, fumes and pulmonary irritants, extreme cold, extreme heat, vibrations and any other condition you identify. Noise is rated separately, from quiet (library) to very loud (jackhammer). Then give the supporting findings.
Yes or no for nine everyday activities: shopping, traveling without a companion, walking without a wheelchair, walker, two canes or two crutches, walking a block on rough or uneven surfaces, using public transportation, climbing a few steps with one hand rail, preparing a simple meal and feeding oneself, personal hygiene, and handling paper or files. Support the answers unless a narrative report is attached.
Section IX asks for any other work-related activities affected by the impairments, how they are affected and the supporting medical findings. Section X asks, if you can say within a reasonable degree of medical probability, the date the limitations you described were first present. Leave it blank only if you lack the information to form that opinion.
Section XI asks whether the limitations have lasted or will last 12 consecutive months, and Section XII whether you examined the claimant. Sign and date under the declaration that you examined all the information on the form and that it is true and correct under penalty of perjury, then print your name, title and medical specialty legibly.
Download the current version from the source each time; forms change without notice.
Medical Source Statement of Ability to Do Work-Related Activities (Physical)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Sources for this guide
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Any treating or examining medical source SSA or the claimant's representative asks for an opinion, most often the physician who manages the physical impairments. SSA collects it from sources reporting on existing medical evidence and from consultative examiners. Section XII asks directly whether you examined the claimant.
Section VIII asks for supporting findings 'unless a narrative report is attached,' so a narrative can carry that section. Every other section still asks you to identify the particular findings, such as exam, imaging, lab results, history and symptoms including pain, and explain why they support the limits you checked.
The form assumes your ratings describe current limitations. Section X asks, if you have enough information to say within a reasonable degree of medical probability, on what date the limitations were first present. Section XI asks whether they have lasted or will last 12 consecutive months, answered yes or no.
It isn't posted on SSA's public forms page. Hearing offices, disability determination services and claimant representatives send it for a specific claimant. The OMB-approved copy is posted on reginfo.gov under control number 0960-0662, together with the mental version, HA-1152.