Disability Evaluation Form Template: Medical Findings & Limits

Disability Evaluation Form Template

[Clinic / Practice Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Fax: [Fax Number]

Email: [Email Address]

1. Patient Identification

Patient Full Name: [First, Middle, Last]

Date of Birth: [MM/DD/YYYY]

Age: [Age]

Gender: [Gender]

Patient ID / Chart Number (if applicable): [ID Number]

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone Number: [Phone Number]

Email Address: [Email Address]

2. Evaluating Provider Information

Provider Full Name: [Name]

Professional Title: [e.g., MD, DO, PhD, PsyD, NP, PA, LCSW]

Specialty: [e.g., Internal Medicine, Psychiatry, Neurology, Orthopedics]

License Number: [Number]

Licensing State/Province: [State/Province]

Practice / Facility Name: [Name]

Address: [Street Address, City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Fax: [Fax Number]

Email: [Email Address]

3. Evaluation Details

Evaluation Type:

• Initial Evaluation

• Re-Evaluation / Follow-Up

Initial Evaluation

Re-Evaluation / Follow-Up

Date(s) of Evaluation: [MM/DD/YYYY]

Date of First Visit with This Provider: [MM/DD/YYYY]

This evaluation is being completed for (check all that apply):

• Disability benefits (insurance / government)

• Workplace accommodations

• School / university disability services

• Legal or court-related matter

• Other: [Describe]

Disability benefits (insurance / government)

Workplace accommodations

School / university disability services

Legal or court-related matter

Other: [Describe]

4. Diagnosis and Medical History (Summary)

Primary Diagnosis (ICD-10 or other code, if known):

[Diagnosis Name and Code]

Secondary Diagnosis(es), if applicable:

[Diagnosis Name and Code]

Date of Onset / Approximate Onset of Symptoms: [MM/DD/YYYY or “Approx. Year”]

Relevant Medical History (brief summary):

• [Key condition or event 1]

• [Key condition or event 2]

• [Surgeries, hospitalizations, or significant events related to condition]

[Key condition or event 1]

[Key condition or event 2]

[Surgeries, hospitalizations, or significant events related to condition]

5. Current Symptoms and Clinical Findings

Current Symptoms Reported by Patient (check or describe):

• Pain (location, intensity, frequency): [Describe]

• Fatigue / low energy

• Shortness of breath

• Dizziness / balance problems

• Weakness / limited strength

• Numbness / tingling

• Cognitive difficulties (memory, concentration)

• Mood symptoms (depression, anxiety, irritability)

• Sensory issues (vision, hearing, light/sound sensitivity)

• Other: [Describe]

Pain (location, intensity, frequency): [Describe]

Fatigue / low energy

Shortness of breath

Dizziness / balance problems

Weakness / limited strength

Numbness / tingling

Cognitive difficulties (memory, concentration)

Mood symptoms (depression, anxiety, irritability)

Sensory issues (vision, hearing, light/sound sensitivity)

Relevant Objective Findings (from exam, tests, imaging, etc.):

[Brief summary of examination findings, test results, imaging, or other objective data.]

6. Functional Limitations – Physical

Based on the patient’s condition, indicate the extent to which the patient can perform the following activities in a typical 8-hour day (or comparable school/workday).

Sitting:

• No limitation

• Up to 2 hours total

• 2–4 hours total

• 4–6 hours total

• 6–8 hours total

  Comments: [Describe need for position changes, special seating, etc.]

No limitation

Up to 2 hours total

2–4 hours total

4–6 hours total

6–8 hours total

Comments: [Describe need for position changes, special seating, etc.]

Standing:

• No limitation

• Up to 2 hours total

• 2–4 hours total

• 4–6 hours total

  Comments: [Describe limitations, need for breaks, assistive devices.]

4–6 hours total

Comments: [Describe limitations, need for breaks, assistive devices.]

Walking:

• No limitation

• Short distances only (e.g., within home or building)

• Moderate distances (e.g., several blocks)

• Requires assistive device (cane, walker, wheelchair)

  Comments: [Describe gait issues, endurance, etc.]

Short distances only (e.g., within home or building)

Moderate distances (e.g., several blocks)

Requires assistive device (cane, walker, wheelchair)

Comments: [Describe gait issues, endurance, etc.]

Lifting / Carrying:

Maximum weight patient can safely lift/carry:

• Up to 10 lbs (4.5 kg)

• 10–20 lbs (4.5–9 kg)

• 20–50 lbs (9–23 kg)

• Over 50 lbs (23 kg)

  Frequency: [Occasionally / Frequently / Never – describe]

Up to 10 lbs (4.5 kg)

10–20 lbs (4.5–9 kg)

20–50 lbs (9–23 kg)

Over 50 lbs (23 kg)

Frequency: [Occasionally / Frequently / Never – describe]

Postural Limitations (check all that apply):

• Difficulty bending / stooping

• Difficulty kneeling / crouching

• Difficulty climbing stairs or ladders

• Difficulty balancing on uneven surfaces

  Comments: [Describe]

Difficulty bending / stooping

Difficulty kneeling / crouching

Difficulty climbing stairs or ladders

Difficulty balancing on uneven surfaces

Comments: [Describe]

7. Functional Limitations – Self-Care and Daily Living

Indicate whether the patient has limitations in:

• Personal hygiene (bathing, grooming): [No limitation / Mild / Moderate / Severe]

• Dressing (including fasteners, shoes): [No limitation / Mild / Moderate / Severe]

• Meal preparation and eating: [No limitation / Mild / Moderate / Severe]

• Housekeeping tasks: [No limitation / Mild / Moderate / Severe]

• Driving or using public transportation: [No limitation / Mild / Moderate / Severe]

Personal hygiene (bathing, grooming): [No limitation / Mild / Moderate / Severe]

Dressing (including fasteners, shoes): [No limitation / Mild / Moderate / Severe]

Meal preparation and eating: [No limitation / Mild / Moderate / Severe]

Housekeeping tasks: [No limitation / Mild / Moderate / Severe]

Driving or using public transportation: [No limitation / Mild / Moderate / Severe]

Comments / Specific Examples:

[Describe how the condition affects daily activities.]

8. Functional Limitations – Cognitive, Emotional, and Behavioral

Cognitive Functions (check all that apply):

• Difficulty concentrating for extended periods

• Short-term memory problems

• Slow information processing

• Difficulty organizing tasks or following complex instructions

Difficulty concentrating for extended periods

Short-term memory problems

Slow information processing

Difficulty organizing tasks or following complex instructions

Emotional / Behavioral Factors:

• Depression or low mood affecting functioning

• Anxiety or panic affecting functioning

• Irritability / mood swings

• Difficulty interacting appropriately with others (coworkers, classmates, public)

Depression or low mood affecting functioning

Anxiety or panic affecting functioning

Irritability / mood swings

Difficulty interacting appropriately with others (coworkers, classmates, public)

Impact on Work / School Tasks:

[Briefly describe how cognitive or emotional symptoms affect attendance, punctuality, productivity, task completion, interactions, etc.]

9. Work / School Capacity and Restrictions

In your clinical opinion, the patient is currently able to:

• Work or attend school full-time without restrictions

• Work or attend school full-time with restrictions

• Work or attend school part-time with restrictions

• Is currently unable to work or attend school

Work or attend school full-time without restrictions

Work or attend school full-time with restrictions

Work or attend school part-time with restrictions

Is currently unable to work or attend school

If restrictions apply, specify (check and describe):

• Limit lifting / carrying

• Limit standing / walking

• Limit repetitive motions (e.g., typing, assembly tasks)

• Avoid heights or hazardous machinery

• Limit exposure to environmental factors (noise, fumes, temperature extremes)

• Limit cognitive load or complex tasks

• Limit stress or high-pressure environments

• Other: [Describe]

Limit lifting / carrying

Limit standing / walking

Limit repetitive motions (e.g., typing, assembly tasks)

Avoid heights or hazardous machinery

Limit exposure to environmental factors (noise, fumes, temperature extremes)

Limit cognitive load or complex tasks

Limit stress or high-pressure environments

Estimated Duration of These Restrictions:

• Less than 3 months

• 3–6 months

• 6–12 months

• More than 12 months

• Permanent / Indefinite (subject to future review)

Less than 3 months

3–6 months

6–12 months

More than 12 months

Permanent / Indefinite (subject to future review)

10. Assistive Devices, Treatments, and Accommodations

Assistive Devices Used or Recommended:

• Cane

• Walker

• Wheelchair

• Braces or orthotics

• Hearing aids

• Visual aids (beyond standard glasses)

• Other: [Describe]

Cane

Walker

Wheelchair

Braces or orthotics

Hearing aids

Visual aids (beyond standard glasses)

Current Treatments (medications, therapies, programs):

[Brief list of current medications, physical therapy, counseling, or other interventions.]

Recommended Workplace / School Accommodations (if known):

• Modified schedule or reduced hours

• Extra breaks for rest, medication, or bathroom

• Remote work / hybrid attendance

• Ergonomic workstation or special seating

• Reduced lifting or physical exertion

• Quiet or low-stimulation environment

• Extended time for tests or assignments

• Note-taking or recording support

• Other: [Describe]

Modified schedule or reduced hours

Extra breaks for rest, medication, or bathroom

Remote work / hybrid attendance

Ergonomic workstation or special seating

Reduced lifting or physical exertion

Quiet or low-stimulation environment

Extended time for tests or assignments

Note-taking or recording support

11. Prognosis and Expected Course

Overall Prognosis:

• Good

• Fair

• Guarded

• Poor

Good

Fair

Guarded

Poor

Comments on Expected Course of Condition:

[Brief statement regarding anticipated improvement, stability, or decline, and any expected milestones.]

12. Additional Comments

Please provide any additional information that may help the requesting agency, employer, or school understand this patient’s limitations and needs:

[Free-text area for provider’s narrative comments.]

13. Provider Certification and Signature

I, [Provider Full Name], certify that the information provided in this Disability Evaluation Form is accurate to the best of my knowledge and is based on my professional evaluation of the patient identified above. This form is intended for use by the requesting organization to understand the patient’s functional limitations and does not guarantee any particular benefit, accommodation, or legal outcome.

Provider Signature: _______________________________

Printed Name: [Provider Full Name, Credentials]

Date: [MM/DD/YYYY]

Optional Stamp or Seal:

[Space for provider or clinic stamp]