Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the form and open it on your device.
2. Begin by filling in the client’s basic information in section A. Enter the name, address, phone number, date of birth, and physician's name, making sure to print or type clearly.
3. In section B, input the patient's vital statistics and presenting symptoms, including height, weight, blood pressure, and muscle strength. Record the diagnosis in the appropriate fields and attach relevant progress notes.
4. For section C, list all medications the patient is currently taking along with their reasons and side effects that could impact work performance.
5. Move to section D, which focuses on physical limitations. It is essential to accurately detail the patient’s capabilities regarding various activities, environmental exposure, and hand actions.
6. In section E, address mental status and specify details about any mental illnesses. Provide all five axes of a DSM-IV diagnosis if applicable.
7. In section F, state whether the patient's medical condition is expected to last at least 12 months and if it prevents them from working. Include the expected duration if relevant.
8. Any additional comments or observations can be recorded in section G. This can be important for a complete assessment.
9. Finally, ensure all fields are completed accurately before signing the form at the designated area. Include your title, license number, and date.
10. After filling out the form, you may need to save changes, download a copy, print it, or share it as per your requirements.

Complete your documents online today to ensure your eligibility for necessary services.