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 1.05 Disorders of the Spine:
o A. Arthritis manifested by
ankylosis or fixation of the cervical or dorsolumbar spine at 30+ or more of flexion
measured from the neutral position, with X-ray evidence of:
o 1. Calcification of the
anterior and lateral ligaments; or
o 2. Bilateral ankylosis of
the sacroiliac joints with abnormal apophyseal articulations; or
o B. Osteoporosis, generalized (established by X-ray)
manifested by pain and limitation of back motion and paravertebral muscle spasm with X-ray
evidence of either:
o 1. Compression fracture of
a vertebral body with loss of at least 50 percent of the estimated height of the vertebral
body prior to the compression fracture, with no intervening direct traumatic episode; or
o 2. Multiple fractures of
vertebrae with no intervening direct traumatic episode; or
o C. Other vertebrogenic disorders (e.g., herniated
nucleus pulposus, spinal stenosis) with the following persisting for at least 3 months
despite prescribed therapy and expected to last 12 months.
With both 1 and 2:
o 1. Pain, muscle spasm, and
significant limitation of motion in the spine; and
o 2. Appropriate radicular
distribution of significant motor loss with muscle weakness and sensory and reflex loss.
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
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