Form SSA-4734-BK Physical Residual Functional Capacity Assessment

Form SSA-4734-BK is a U.S. Social Security Administration form also known as the "Physical Residual Functional Capacity Assessment". The latest edition of the form was released in August 1, 2017 and is available for digital filing.

Download a PDF version of the Form SSA-4734-BK down below or find it on U.S. Social Security Administration Forms website.

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Form SSA-4734-BK (08-2017)
Discontinue Prior Editions
Social Security Administration
Page 1 of 7
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
SOCIAL SECURITY NUMBER
CLAIMANT:
NUMBERHOLDER (IF CDB OR DWB CLAIM)
RFC ASSESSMENT IS FOR:
Date 12 Months After Onset
PRIMARY DIAGNOSIS:
Current Evaluation
(Date)
SECONDARY DIAGNOSIS:
Date Last Insured
(Date)
OTHER ALLEGED IMPAIRMENTS:
Other (Specify):
OTHER ALLEGED IMPAIRMENTS CONTINUED:
1. LIMITATIONS:
For Each Section A - F
Base your conclusions on all evidence in file (clinical and laboratory findings, symptoms, observations,
lay evidence, reports of daily activities, etc.).
Check the blocks which reflect your reasoned judgment.
Describe how the evidence substantiates your conclusions (Cite specific clinical and laboratory
findings, observations, lay evidence, etc.).
Ensure that you have:
Requested appropriate medical opinions (DI 22505.000ff. and DI 22510.000ff.) and that you have given
appropriate consideration to medical opinions (See Section 3.).
• Considered and responded to any alleged limitations imposed by symptoms (pain, fatigue, etc.)
attributable, in your judgment, to a medically determinable impairment. Discuss your assessment of
symptom-related limitations in the explanation for your conclusions in A - F below (See also Section 2.).
• Responded to all allegations of physical limitations or factors which can cause physical limitations.
Frequently means occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous).
Occasionally means occurring from very little up to one-third of an 8-hour workday
(cumulative, not continuous).
Form SSA-4734-BK (08-2017)
Discontinue Prior Editions
Social Security Administration
Page 1 of 7
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
SOCIAL SECURITY NUMBER
CLAIMANT:
NUMBERHOLDER (IF CDB OR DWB CLAIM)
RFC ASSESSMENT IS FOR:
Date 12 Months After Onset
PRIMARY DIAGNOSIS:
Current Evaluation
(Date)
SECONDARY DIAGNOSIS:
Date Last Insured
(Date)
OTHER ALLEGED IMPAIRMENTS:
Other (Specify):
OTHER ALLEGED IMPAIRMENTS CONTINUED:
1. LIMITATIONS:
For Each Section A - F
Base your conclusions on all evidence in file (clinical and laboratory findings, symptoms, observations,
lay evidence, reports of daily activities, etc.).
Check the blocks which reflect your reasoned judgment.
Describe how the evidence substantiates your conclusions (Cite specific clinical and laboratory
findings, observations, lay evidence, etc.).
Ensure that you have:
Requested appropriate medical opinions (DI 22505.000ff. and DI 22510.000ff.) and that you have given
appropriate consideration to medical opinions (See Section 3.).
• Considered and responded to any alleged limitations imposed by symptoms (pain, fatigue, etc.)
attributable, in your judgment, to a medically determinable impairment. Discuss your assessment of
symptom-related limitations in the explanation for your conclusions in A - F below (See also Section 2.).
• Responded to all allegations of physical limitations or factors which can cause physical limitations.
Frequently means occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous).
Occasionally means occurring from very little up to one-third of an 8-hour workday
(cumulative, not continuous).
Form SSA-4734-BK (08-2017)
Page 2 of 7
A. EXERTIONAL LIMITATIONS
None established. (Proceed to section B.)
1. Occasionally lift and/or carry (including upward pulling) (maximum) - when less than one-third of the time or less than
10 pounds, explain the amount (time/pounds) in item 6.
less than 10 pounds
10 pounds
20 pounds
50 pounds
100 pounds or more
2. Frequently lift and/or carry (including upward pulling) (maximum) - when less than two-thirds of the time or less than 10
pounds, explain the amount (time/pounds) in item 6.
less than 10 pounds
10 pounds
25 pounds
50 pounds or more
3. Stand and/or walk (with normal breaks) for a total of -
less than 2 hours in an 8-hour workday
at least 2 hours in an 8-hour workday
about 6 hours in an 8-hour workday
medically required hand-held assistive device is necessary for ambulation
4. Sit (with normal breaks) for a total of -
less than about 6 hours in an 8-hour workday
about 6 hours in an 8-hour workday
must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in item 6.)
5. Push and/or pull (including operation of hand and/or foot controls) -
unlimited, other than as shown for lift and/or carry
limited in upper extremities (describe nature and degree)
limited in lower extremities (describe nature and degree)
6. Explain how and why the evidence supports your conclusions in items 1 through 5.
Cite the specific facts upon which your conclusions are based.
Page 3 of 7
Form SSA-4734-BK (08-2017)
B. POSTURAL LIMITATIONS
None established. (Proceed to section C.)
Frequently
Occasionally
Never
1. Climbing - ramp/stairs
- ladder/rope/scaffolds
2. Balancing
3. Stooping
4. Kneeling
5. Crouching
6. Crawling
7. When less than two-thirds of the time for frequently or less than one-third for occasionally, fully describe and explain. Also,
explain how and why the evidence supports your conclusions in items 1 through 6. Cite the specific facts upon which your
conclusions are based.
C. MANIPULATIVE LIMITATIONS
None established. (Proceed to section D.)
LIMITED
UNLIMITED
1. Reaching all directions (including overhead)
2. Handling (gross manipulation)
3. Fingering (fine manipulation)
4. Feeling (skin receptors)
5. Describe how the activities checked "limited" are impaired. Also, explain how and why the evidence supports
your conclusions in items 1 through 4. Cite the specific facts upon which your conclusions are based.
Page 4 of 7
Form SSA-4734-BK (08-2017)
D. VISUAL LIMITATIONS
None established. (Proceed to section E.)
LIMITED
UNLIMITED
1. Near acuity
2. Far acuity
3. Depth perception
4. Accommodation
5. Color Vision
6. Field of vision
7. Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports your
conclusions in items 1 through 6. Cite the specific facts upon which your conclusions are based.
E. COMMUNICATIVE LIMITATIONS
None established. (Proceed to section F.)
LIMITED
UNLIMITED
1. Hearing
2. Speaking
3. Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports your
conclusions in items 1 and 2. Cite the specific facts upon which your conclusions are based.
Page 5 of 7
Form SSA-4734-BK (08-2017)
F. ENVIRONMENTAL LIMITATIONS
AVOID
AVOID
AVOID ALL
MODERATE
CONCENTRATED
None established. (Proceed to Section 2.)
EXPOSURE
UNLIMITED
EXPOSURE
EXPOSURE
1. Extreme cold
2. Extreme heat
3. Wetness
4. Humidity
5. Noise
6. Vibration
7. Fumes, odors,
dust, gases,
poor ventilation,
etc.
8. Hazards
(machinery, heights, etc.)
9. Describe how these environmental factors impair activities and identify hazards to be avoided. Also, explain how
and why the evidence supports your conclusions in items 1 through 8. Cite the specific facts upon which your
conclusions are based.

Download Form SSA-4734-BK Physical Residual Functional Capacity Assessment

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