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Disability Evaluation Form Template
Provide a clear medical disability evaluation with structured information on diagnosis, limitations, and recommended accommodations.
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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
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]
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]
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]
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.]
Standing:
No limitation
Up to 2 hours total
2–4 hours total
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.]
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]
Postural Limitations (check all that apply):
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]
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
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)
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
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]
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)
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]
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]
11. Prognosis and Expected Course
Overall Prognosis:
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]
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Learn more about
Disability Evaluation Form Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
DISABILITY EVALUATION FORM TEMPLATE FAQ
What is a disability evaluation form?
A disability evaluation form is a structured document that a licensed healthcare provider completes to describe a patient’s medical conditions, functional limitations, and ability to work or perform daily activities. It is often used by employers, schools, insurance companies, government agencies, or courts when they review disability claims or accommodation requests.
Who can complete a disability evaluation form?
A disability evaluation form is typically completed by a licensed healthcare professional who knows the patient’s condition, such as a primary care physician, specialist, psychologist, psychiatrist, or other licensed clinician. The specific type of provider required may depend on the program or agency requesting the evaluation.
What information should be included in a disability evaluation form?
A helpful disability evaluation form usually includes: patient identification, provider identification and credentials, diagnosis and medical history, current symptoms, objective findings, functional limitations (physical, cognitive, emotional), expected duration of impairment, work or school capacity, recommended restrictions, and any assistive devices or accommodations that may help the patient function safely and effectively.
When is a disability evaluation form used?
Disability evaluation forms are used in many contexts, including applications for disability benefits, workplace accommodation requests, school or university disability services, insurance claims, fitness-for-duty reviews, or legal proceedings. The requesting organization may provide its own form, but this template can be adapted when a general medical statement is requested.
Does completing a disability evaluation form guarantee benefits or legal outcomes?
No. A disability evaluation form is one piece of information that agencies, employers, schools, or courts may consider when making decisions. Completing the form does not guarantee that benefits, accommodations, or legal relief will be granted. Those decisions are made by the requesting organization under its own rules and applicable laws.
Can AI Lawyer help me with a disability evaluation form?
Yes. AI Lawyer can help structure and format the disability evaluation form by suggesting clear sections and wording. However, only a licensed healthcare provider should supply medical diagnoses, clinical opinions, and signatures. This template and any AI-generated text are for document organization only and are not medical, psychological, or legal advice. For case-specific guidance, consult qualified professionals.
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