Sample MSS

Patient Name:

  1. Please describe your medical area of expertise and the length of time you have treated the patient.
  2. Please give a brief description of the patient’s medical history and diagnoses.
  3. Please describe what symptoms the patient has and is likely to experience on an average day as a result of a medical impairments.
  4. If the patient were to return to a full 40-hour workweek, describe what work accommodations would a require.
    1. Standing
    2. Sitting
    3. Using hands (typing, writing, etc.)
    4. Unscheduled Absences or Extra Work Breaks
  5. In your medical opinion, will the problems you described in question #4 present themselves at least two or three times a week?   Yes     No    (If yes, feel free to explain.)
  6. In your medical opinion, are the patient’s subjective complaints within the range of what can be expected from individuals with the same type of medical conditions? 
    1. Yes, the patient is being forthright with a symptoms    
    2. No the patient is malingering  
  7. Have these limitations existed to the extent described since ________ (insert date)?   Yes     No   

Please feel free to provide additional comments or explanations.

 Doctor's Signature:  ___________________

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