Medical opinion form for chronic venous insufficiency

CHRONIC VENOUS INSUFFICIENCY
TREATING PHYSICIAN
DATA SHEET
Long form
FOR REPRESENTATIVE USE ONLY
REPRESENTATIVE’S NAME AND ADDRESS
REPRESENTATIVE’S TELEPHONE
REPRESENTATIVE’S EMAIL
PHYSICIAN’S NAME AND ADDRESS
PHYSICIAN’S TELEPHONE
PHYSICIAN’S EMAIL
PATIENT’S TELEPHONE
PATIENT’S NAME AND ADDRESS
PATIENT’S EMAIL
PATIENT’S SSN
LEVEL OF ADJUDICATION:
Initial DDS Recon DDS
TYPE OF CLAIM:
Initial CDR Hearing Officer
Title 2 DIB/DWB CDB Administrative Law Judge Appeals Council
Title 16 DI DC Federal District Court Federal Appeals Court
Dear Dr.
We are pursuing the Social Security disability claim for the above-named individual (the “patient”). We understand how
valuable your time is, and this data sheet has been designed to allow you to provide medical information in an efficient
and organized way. As a treating physician, your records and medical judgment are vital in arguing for a fair disability
determination for the patient before the Social Security Administration (SSA). If you receive multiple data sheets, please
disregard repetitive questions.
Your medical specialty please:
Note 1: This document will not have legal validity for Social Security disability determination purposes unless
completed by a licensed medical doctor or osteopath.
Note 2: This document only concerns chronic venous insufficiency. Other impairments and limitations resulting
from a combination of impairments should be considered separately.
Note 3: Age, degree of general physical conditioning, sex, body habitus (i.e., natural body build, physique,
constitution, size, and weight), insofar as they are unrelated to the patient’s medical disorder and symptoms,
should not be considered when assessing the functional severity of the impairment.
Copyright David A. Morton III, M.D.
Form 4.11 (2003)

I. Has the patient had any of the following impairments?
Heart failure (Complete Form 4.02.)
Hypertension (Complete Form 4.03.)
Peripheral arterial disease (Complete Form 4.12.)
II. Does the patient have chronic venous insufficiency of a lower extremity?
If Yes, please answer the following questions.
III. Does the patient currently have brawny edema?
Left leg Yes No Unknown
Right leg Yes No Unknown
If Yes, how long has the edema been continuously present, by your examinations?
Yes No Unknown
If Yes, please give a detailed description of the extent of brawny edema, and rate severity on a scale of 1 – 4.
(Photographs are very helpful, if available.)
IV. Are any of the following abnormalities currently present? (provide photo if available, and provide a detailed
description)
A. Left leg.
Superficial varicosities (include location and veins involved, and time present despite treatment)
Stasis dermatitis (include area of leg involved, and time present despite treatment)
Ulceration (include location and size, and time present despite treatment)
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 2 of 8

B. Right leg.
Superficial varicosities (include location and veins involved, and time present despite treatment)
Stasis dermatitis (include area of leg involved, and time present despite treatment)
Ulceration (include location and size, and time present despite treatment)
V. Has the patient had venous imaging (e.g., x-ray contrast venography, MRI venography?)
If Yes, please attach results and discuss important relevant findings.
Yes No Unknown
VI. Has the patient had any other venous studies performed, such as venous ultrasound?
If Yes, please attach results and discuss important relevant findings.
Yes No Unknown
VII. Response to Treatment.
Please specify the last date you examined the patient. Date: ___________
A. Medical therapy
1. Specify current medications and doses of drugs, or other medical treatment.
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 3 of 8

2. Has the patient complained of drug-related symptoms? Yes No
If Yes, what were the side-effects and treatment response?
taking.
3. Please list all non-prescription drugs, herbs, or other “alternative medicine” treatments the patient may be
B. Surgical therapy
Has the patient had surgery for venous disease? Yes No Unknown
If Yes, specify date and nature of surgery and attach operative report if available.
Did surgery relieve or improve the patient’s function or symptoms? Yes No Unknown
Comments:
C. Treatment compliance?
Is the patient compliant with treatment? Yes No Unknown
Comments:
D. Current Clinical Condition.
(Please include or attach physical examination, and other clinical vascular information not previously discussed. )
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 4 of 8

VIII. Current Functional Limitations and Capacities.
Note: The following questions apply only to patients at least 18 years of age.
In respect to the patient’s venous disease, please give your opinion in response to the following questions:
A. Is the patient able to stand and/or walk 6 – 8 hours daily on a long term basis without worsening of chronic venous
insufficiency?
Yes No Unknown
If No, how long can the patient stand and/or walk (with normal breaks) in a 6 – 8 hour work day without
worsening of venous insufficiency (and assuming compliance with treatment such as support stockings)?
B. What maximum weight can the patient lift and/or carry occasionally (cumulatively not continuously)?
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
100 lbs.
Other (lbs.)
Unknown
C. What weight can the patient lift and/or carry frequently (cumulatively not continuously)?
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs. or more
Other (lbs.)
D. Work environment temperature restrictions.
Unknown
1. Aside from exertional considerations such as lifting and carrying, does the patient have restrictions against
exposure to extreme heat or cold?
If Yes, please define:
Extreme heat (F°):
Extreme cold (F°):
Yes No Unknown
Check the appropriate boxes:
“Concentrated exposure” means 1/3 to 2/3 of 8 hour workday.
“Moderate exposure” means very little up to 1/3 of 8 hour workday.
Unlimited
Avoid
Concentrated
Exposure
Avoid Even
Moderate
Exposure
Avoid All
Exposure
Extreme cold
Extreme heat
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 5 of 8

2. Would the patient’s exertional capacities for lifting and carrying (as described in B and C above) be further
reduced by work in extremely hot or cold environments?
Yes No Unknown
If Yes, please use the following scale to indicate lifting and carrying capacity in relation to work environment
temperature on blank chart following the example.
EXAMPLE ONLY
Environmental Work
Temperature
(Degrees Fahrenheit)
Patient Can Lift
(Pounds)
O/F
100 and over N
95 – 100 N
90 – 95 N
85 – 90 10/5
80 – 85 20/10
75 – 80 20/10
70 – 75 50/25
65 – 70 50/25
60 – 65 20/10
55 – 60 20/10
50 – 55 20/10
45 – 50 10/5
40 – 45 10/5
35 – 40 N
30 – 35 N
25 – 30 N
20 – 25 N
15 – 20 N
10 – 15 N
5 – 10 N
0 and below N
N = no exposure
O = weight to be occasionally lifted
F = weight to be frequently lifted
E. Specific types of exertion.
FOR PHYSICIAN TO COMPLETE
Environmental Work
Temperature
(Degrees Fahrenheit)
100 and over
95 – 100
90 – 95
85 – 90
80 – 85
75 – 80
70 – 75
65 – 70
60 – 65
55 – 60
50 – 55
45 – 50
40 – 45
35 – 40
30 – 35
25 – 30
20 – 25
15 – 20
10 – 15
5 – 10
0 and below
N = no exposure
O = weight to be occasionally lifted
F = weight to be frequently lifted
Patient Can Lift
(Pounds)
O/F
1. Can the following activities be performed (from a venous disease standpoint) while not lifting or carrying the
amount of weight specified previously for given temperature conditions, or not applying equivalent force?
Leg controls: never occasionally frequently
Climbing: never occasionally frequently
Squatting: never occasionally frequently
Unknown
2. Can the following activities be performed (from a venous disease standpoint) while lifting or carrying the
amount of weight specified previously for given temperature conditions, or while applying equivalent force?
Leg controls: never occasionally frequently
Climbing: never occasionally frequently
Squatting: never occasionally frequently
Unknown
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 6 of 8

IX. Additional Physician Comments. (Also list other disorders of which you are aware.)
Physician’s Name (print or type)
Physician’s Signature (no name stamps)
Date
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 7 of 8

X. Representative Notes.
Copyright David A. Morton III, M.D.
Form 4.11 (2003)
Page 8 of 8