Example one:
On the SSA-3373-BK (Function Report – Adult), an individual says they can only walk a few blocks due
to pain. The medical evidence includes a knee x-ray showing moderate degenerative
changes and a physical exam indicating limited range of motion, joint effusion, and
a mildly antalgic gait.
At step one of symptom evaluation process, the objective findings establish the individual
has an MDI that could reasonably be expected to produce the symptom of pain.
Example two:
On the SSA-3368-BK (Disability Report – Adult), an individual alleges depression, problems concentrating,
and difficulty getting along with others but they did not identify a healthcare provider
who treats their mental allegations. The individual completed and returned the SSA-3373-BK
and reports difficulties in multiple domains of mental functioning, such as self-care
(needs reminders to shower) and social activities (i.e., no longer spends time with
friends or family, communicates only by text message). The DDS schedules a consultative
examination (CE) to establish a mental MDI.
At the CE, the individual reports isolating from friends and family during depressive
episodes. The mental status exam indicates the individual has a flat affect with fair
eye contact and limited insight and judgment. Additionally, they struggled to perform
serial 7's and recalled 1 out of 3 objects after a delay. The CE source diagnosed
the individual with major depressive disorder.
At step one of the symptom evaluation process, the objective findings establish the
individual has an MDI that could reasonably be expected to produce the individual's
symptoms of "problems concentrating" and "difficulty getting along with others."