How to use this: print it, take it to your doctor, and ask them to fill it in and sign. Bring the signed copy to Social Security or add it to your records. Back to resources
NEW LIFE DISABILITY — FOR THE TREATING DOCTOR
Treating Doctor's Statement of Functional Limits
Your patient is applying for Social Security disability benefits. Social Security decides claims on what a person can still do despite their conditions. Your opinion of your patient's limits — based on your examinations, test results and treatment — is important evidence. Please answer from your own clinical judgment. This is not a Social Security form.
Patient name:
Date of birth:
Doctor's name:
Practice / specialty:
Treating since:
Date of last visit:
1. Diagnoses and findings
Diagnoses you treat this patient for, and the clinical findings / tests that support them
2. Symptoms and treatment
Main symptoms (pain, fatigue, breathing, mood, cognition…) and how severe / how often
Current treatment and medications, and any side effects that affect work (drowsiness, dizziness, slowed thinking…)
3. Physical limits (your best estimate)
| Sit at one time | ☐ < 15 min☐ 15–30 min☐ 30–60 min☐ 1–2 hrs☐ 2+ hrs |
| Stand at one time | ☐ < 15 min☐ 15–30 min☐ 30–60 min☐ 1–2 hrs☐ 2+ hrs |
| Walk at one time | ☐ < 1 block☐ 1–2 blocks☐ ¼ mile☐ ½ mile☐ 1+ mile |
| Sit, total in an 8-hour day | ☐ < 2 hrs☐ 2–4 hrs☐ 4–6 hrs☐ 6+ hrs |
| Stand / walk, total in an 8-hour day | ☐ < 2 hrs☐ 2–4 hrs☐ 4–6 hrs☐ 6+ hrs |
| Lift and carry occasionally | ☐ < 10 lb☐ 10 lb☐ 20 lb☐ 50 lb☐ 50+ lb |
| Lift and carry frequently | ☐ < 10 lb☐ 10 lb☐ 20 lb☐ 50 lb |
Needs to change position or lie down during the day?
☐ No ☐ Yes — about every ____ minutes, for ____ minutes ☐ Needs to lie down ____ times a day
Uses an assistive device?
☐ None ☐ Cane ☐ Walker ☐ Wheelchair ☐ Brace / other: __________
4. Postural and manipulative activities — how often can the patient do these in a workday?
| Activity | Never | Occasionally (up to ⅓ of day) | Frequently (⅓–⅔) | Constantly |
|---|---|---|---|---|
| Bend / stoop | ☐ | ☐ | ☐ | ☐ |
| Kneel / crouch | ☐ | ☐ | ☐ | ☐ |
| Climb stairs | ☐ | ☐ | ☐ | ☐ |
| Reach overhead | ☐ | ☐ | ☐ | ☐ |
| Use hands for fine work (buttons, keyboard) | ☐ | ☐ | ☐ | ☐ |
| Grip / grasp | ☐ | ☐ | ☐ | ☐ |
5. Mental and cognitive abilities (if relevant)
| Ability | No limit | Mild | Moderate | Marked | Extreme |
|---|---|---|---|---|---|
| Understand, remember and carry out simple instructions | ☐ | ☐ | ☐ | ☐ | ☐ |
| Understand, remember and carry out detailed instructions | ☐ | ☐ | ☐ | ☐ | ☐ |
| Maintain attention and concentration for 2-hour blocks | ☐ | ☐ | ☐ | ☐ | ☐ |
| Keep a regular schedule and be on time | ☐ | ☐ | ☐ | ☐ | ☐ |
| Work with co-workers and the public without being distracted or upset | ☐ | ☐ | ☐ | ☐ | ☐ |
| Deal with normal work stress and changes in routine | ☐ | ☐ | ☐ | ☐ | ☐ |
6. Attendance and pace
Off-task because of symptoms, as a share of a workday: ☐ under 5% ☐ 5–10% ☐ 10–20% ☐ over 20%
Likely to miss work because of the conditions or treatment: ☐ less than 1 day a month ☐ about 1 day ☐ about 2 days ☐ 3 days ☐ 4 or more days a month
Would need unscheduled breaks? ☐ No ☐ Yes — about ____ a day, ____ minutes each
7. Duration and onset
These limits have lasted, or are expected to last, 12 months or longer: ☐ Yes ☐ No ☐ Uncertain
The earliest date these limits applied, to the best of your knowledge: ______________
Anything else Social Security should understand about this patient's ability to work
Doctor's signature
Date · License / NPI (optional)
Prepared by New Life Disability, a private company not affiliated with the Social Security Administration. This statement is the treating doctor's own opinion; it is not a Social Security determination and does not replace Social Security's forms. Social Security services are free at ssa.gov and 1-800-772-1213.