Heading

Complete each applicable item.

I.

LIMITATIONS

General Instructions

1. Evaluate all the evidence.

2. No limitations/restrictions - Check “none established.” Proceed to the next section.

3. Explain how and why the medical evidence (signs, symptoms, laboratory findings and other evidence (e.g., observations, lay information, daily activities) supports your conclusions. Cite specific facts.

4. Address and discuss any allegations of physical limitations or factors which can cause physical limitations.

5. Discuss and resolve (in part IV) any inconsistencies or conflicts of evidence with your conclusions.

6. Use the “Current Evaluation” block in cases when the evaluation is for AOD through present and the duration requirement has been met.

   Use the “Current Evaluation” block in cases when the AOD is within 12 months of adjudication and the impairment does not preclude SGA at the time of the RFC assessment.

   See the NOTE in POMS DI 25505.030E.1.

   Use the “Date Last Insured” block for T2 cases only, when DLI has expired in the past. Enter the DLI “(Date)” in the space provided.

   Use the “Date 12 Months After Onset” block for cases when duration is an issue. Enter the “(Date)” to which you are projecting in the space provided.

   Use the “Other (Specify)” block for any situation not covered by the other three blocks (e.g. multiple RFCs or closed periods). Enter the applicable information describing the situation in the space provided.

Specific Instructions

  A.

Exertional
Limitations

1. Check the blocks A.1.-5. that represent the maximum amount the individual can clearly do on a sustained basis.

2. Where an individual can do a maximum amount greater than the amount checked (on a sustained basis), describe and explain the amount at the end of the pertinent section.

3. In A.3., if “medically required hand-held assistive device is necessary for ambulation” is checked, explain in A.6. Give appropriate weight to treating source opinion(s).

NOTE: If the individual cannot lift even 10 pounds, check “less than 10 pounds.” This information may be pertinent to a determination of ability to do past relevant work. Therefore, specifically describe (in A.6.) the individual's lifting capabilities (e.g., can /cannot occasionally lift a phone receiver).

B.

Postural
Limitations

1. Check blocks B. 1.-6. that represent the maximum amount the individual can do on a sustained basis.

2. For B. 1. Climbing – when appropriate, you may circle the specific sub-limitation for ladder/rope/scaffold and specify as Occasionally or Never, while categorizing ramps/stairs as Frequently. Any manual annotations should be clearly marked and easily understandable by subsequent reviewers.

3. When an individual can perform postural limitations less than two-thirds of the time Frequently or less than one-third Occasionally, fully describe in B. 7 how the evidence supports your conclusions and cite the pertinent medical evidence in detail.

C.

Manipulative
Limitations

1. Check blocks C.1.-5. to indicate whether the functions are limited or unlimited.

2. Describe in detail in C. 5 how the functions marked “limited” are impaired and cite the specific medical evidence which supports those conclusions.

NOTE: When limiting a claimant to reaching, specify whether the limitation is for reaching in all directions or for overhead reaching only. In addition, specify the frequency of the limitation.

  D.

Visual Impairments

Record the ability or inability to work with large or small objects, to follow written instructions, or to avoid ordinary hazards of the work place.

  E.

Hearing and Speaking Impairments

Explain how the limitations would effect communication in the work place.

NOTE: In each section A.-E. above, discuss allegations of symptom-related limitations (e.g., pain or reduced stamina) and of physical limitations not supported by clinical evidence.

II.

SYMPTOM
LIMITATIONS

When not addressed in Section I, discuss alleged symptom-related limitations. See DI 24515.062 and DI 24510.055 (SSA-4734-BK, part II).

III.

MEDICAL SOURCE STATEMENT

1. Always complete.

2. Opinion requested but not provided - Check “No” and show the date of opinion request in the space to the left.

3. Medical Source Conclusions Are More Limited Than RFC Findings - Explain why these conclusions are not supported by, or consistent with, the evidence (e.g., signs, symptoms, and laboratory findings, observations, lay evidence). (See DI 24510.010.)

4. RFC Limitations Are Equal to, or More Limited Than, Medical Source Conclusions

   No explanation is necessary.

5. Medical Source Uses Imprecise or Undefined Terms

   • Obtain an exact definition (e.g., Worker's Compensation or Veteran's Administration ratings).

   • Always resolve inconsistencies in interpretation.

   • When inconsistencies cannot be resolved, explain why the medical source opinion is being rejected entirely, or in part.

IV.

ADDITIONAL
COMMENTS

Use for a discussion of limitations due to a physical impairment(s) not addressed in section I, comments not requested above, and continuation of previous comments.

V.

1. Select the MC or SDM block as appropriate.

   NOTE: It is important to check the correct box. It must be clear to the appeal-level adjudicator when the SSA-4734-BK was completed by an SDM because SDM-completed forms are not opinion evidence at the appeal levels.

2. Only MCs should select the “THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION” block. The MC does not select this box when the assessment is preliminary, advisory, or partial.

3. Depending on the DDS Legacy system, the MC code may need to be entered manually prior to signing. If necessary, MCs should input the appropriate code in the MEDICAL CONSULTANT’S CODE block. SDMs should not make any entry in this block.

4. Sign and date the form.