Valuable Medical Forms for the disabled from Hugh D. Cox, Attorney in Greenville NC, proudly representing the disabled for rightful veterans benefits, Social Security benefits and Workers Compensation throughout North Carolina
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Medical Forms
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The heart of any disability case is the medical evidence from a specialized physician. Medical records are usually not enough to achieve disability. My office uses these forms for clients to present to the treating physician(s) to clearly define the extent of and limitations/restrictions of disability:
Disability Forms
(PDF) for Social Security, Work Comp and Veteran Service Connection - to be
completed by physician.
Example of Listings (from the Code
of Federal Regulations)
Listing 1.04 Disorders of the Spine:
1.04
Disorders of the spine (e.g., herniated nucleus pulposus, spinal
arachnoiditis, spinal stenosis, osteoarthritis, degenerative disc disease, facet
arthritis, vertebral fracture), resulting in compromise of a nerve root
(including the cauda equina) or the spinal cord. With:
A. Evidence of nerve root compression characterized by neuro-anatomic distribution of pain, limitation of motion of the spine, motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss and, if there is involvement of the lower back, positive straight-leg raising test (sitting and supine);
OR
B. Spinal arachnoiditis, confirmed by an operative note or pathology report of tissue biopsy, or by appropriate medically acceptable imaging, manifested by severe burning or painful dysesthesia, resulting in the need for changes in position or posture more than once every 2 hours;
or
C. Lumbar spinal stenosis resulting in pseudoclaudication, established by findings on appropriate medically acceptable imaging, manifested by chronic nonradicular pain and weakness, and resulting in inability to ambulate effectively, as defined in 1.00B2b.
Fibromyalgia
or fatigue syndrome Use
11.09 (although
it shows multiple sclerosis) or 14.06
Listing 11.09 Multiple
sclerosis.
With:
A. Disorganization of motor function as described in 11.04B;
or
B. Visual or mental impairment as described under the criteria in 2.02,
2.03, 2.04, or 12.02;
or
C. Significant, reproducible fatigue of motor function with substantial
muscle weakness on repetitive activity, demonstrated on physical examination,
resulting from neurological dysfunction in areas of the central nervous system
known to be pathologically involved by the multiple sclerosis process.
20 CFR Pt. 404, Subpt. P, App.
1, Listing of Impairments
OR:
Listing 14.06 below:
14.02
Systemic lupus erythematosus.
Documented as described in 14.00B1, with:
A. One of the following:
1. Joint involvement, as described under the criteria in 1.00;
or
2. Muscle involvement, as described under the criteria in 14.05;
or
3. Ocular involvement, as described under the criteria in 2.00ff;
or
4. Respiratory involvement, as described under the criteria in 3.00ff;
or
5. Cardiovascular involvement, as described under the criteria in 4.00ff
or 14.04D;
or
6. Digestive involvement, as described under the criteria in 5.00ff;
or
7. Renal involvement, as described under the criteria in 6.00ff;
or
8. Skin involvement, as described under the criteria in 8.00ff;
or
9. Neurological involvement, as described under the criteria in 11.00ff;
or
10. Mental involvement, as described under the criteria in 12.00ff.
or
B. Lesser involvement of two or more organs/body systems listed in
paragraph A, with significant, documented, constitutional symptoms and signs of
severe fatigue, fever, malaise, and weight loss.
At least one of the organs/body systems must be involved to at least a
moderate level of severity.
14.03 Systemic vasculitis.
Documented as described in 14.00B2, including documentation by
angiography or tissue biopsy, with:
A. Involvement of a single organ or body system, as described under the
criteria in 14.02A.
or
B. Lesser involvement of two or more organs/body systems listed in
14.02A, with significant, documented, constitutional symptoms and signs of
severe fatigue, fever, malaise, and weight loss.
At least one of the organs/body systems must be involved to at least a
moderate level of severity.
14.04 Systemic sclerosis and scleroderma.
Documented as described in 14.00B3, with:
A. One of the following:
1. Muscle involvement, as described under the criteria in 14.05;
or
2. Respiratory involvement, as described under the criteria in 3.00ff;
or
3. Cardiovascular involvement, as described under the criteria in 4.00ff;
or
4. Digestive involvement, as described under the criteria in 5.00ff;
or
5. Renal involvement, as described under the criteria in 6.00ff.
or
B. Lesser involvement of two or more organs/body systems listed in
paragraph A, with significant, documented, constitutional symptoms and signs of
severe fatigue, fever, malaise, and weight loss.
At least one of the organs/body systems must be involved to at least a
moderate level of severity.
or
C. Generalized scleroderma with digital contractures.
or
D. Severe Raynaud's phenomena, characterized by digital ulcerations,
ischemia, or gangrene.
14.05 Polymyositis or dermatomyositis.
Documented as described in 14.00B4, with:
A. Severe proximal limb-girdle (shoulder and/or pelvic) muscle weakness,
as described in 14.00B4.
or
B. Less severe limb-girdle muscle weakness than in 14.05A, associated
with cervical muscle weakness and one of the following to at least a moderate
level of severity:
1. Impaired swallowing with dysphagia and episodes of aspiration due to
cricopharyngeal weakness, or
2. Impaired respiration due to intercostal and diaphragmatic muscle
weakness.
or
C. If associated with malignant tumor, as described under the criteria in
13.00ff.
or
D. If associated with generalized connective tissue disease, described
under the criteria in 14.02, 14.03, 14.04, or 14.06.
14.06 Undifferentiated connective
tissue disorder.
Documented as described in 14.00B5, and with impairment as described
under the criteria in 14.02A, 14.02B, or 14.04.
20 CFR Pt. 404, Subpt. P, App. 1, Listing of Impairments
