Get Crohn's & Colitis Medical Source Statement 2009-2025

The Crohn's & Colitis Medical Source Statement is an essential document for evaluating a person's medical condition and its impact on their functional abilities. This guide provides step-by-step instructions to help users accurately complete the form online.

Follow the steps to fill out the form easily and accurately.

1. Press the ‘Get Form’ button to access the form and open it in your browser window.
2. Begin by entering the patient's name and social security number in the designated fields at the top of the form.
3. In the first section, provide the frequency and length of contact with the patient, which helps assess the extent of the healthcare provider’s relationship.
4. Record the patient’s diagnoses in the relevant section to clearly identify their medical conditions.
5. Next, complete the prognosis section, outlining expected recovery or status.
6. Identify the patient’s symptoms from the provided list, marking any that apply, such as chronic diarrhea, abdominal pain, and others.
7. If applicable, describe the nature and characteristics of the patient's pain in the designated area.
8. For episodic impairments, detail the nature, precipitating factors, and frequency of these episodes.
9. Clearly identify any clinical findings and objective signs observed during assessments.
10. Detail any treatment the patient has received and the associated responses, including side effects that may impact the ability to work.
11. Indicate whether the patient’s impairments are expected to last at least twelve months.
12. Report on whether emotional factors contribute to the patient’s symptoms and functional limitations.
13. Identify any psychological conditions that affect the patient's physical health.
14. Estimate the patient’s functional limitations based on their capacity to walk, sit, and stand, using the provided options.
15. Address whether the patient requires specific job accommodations such as accessibility to restrooms or flexibility of position.
16. Document how many pounds the patient can lift and carry within a competitive work scenario.
17. Fill out the section relating to how often the patient can perform various physical activities.
18. Estimate the percentage of time the patient is likely to be off task during work.
19. Assess the patient's ability to tolerate work stress, providing explanations where necessary.
20. Conclude with any additional limitations that may affect the patient's ability to sustain employment.
21. Finally, review the completed form for accuracy, print or download it, and ensure it is signed and dated by the healthcare provider.

Fill out your Crohn's & Colitis Medical Source Statement online today to ensure accurate medical evaluation.