Residual Functional Capacity

RESIDUAL FUNCTIONAL CAPACITY

SIDE EFFECTS OF MEDICATION

Name:
Claim #:
Date of Injury:
Please Print Name of Medical Evaluator:
Medical Specialty:
What is the first date patient’s impairment(s) became “severe” meaning that his/her impairment(s) caused interference ADL’s or ability to work? / Date:
When did you begin treating the patient? / Date:
How frequently do you see your patient? / Date:

Claimantreported taking the following medication(s) for his or her medical condition(s):

Claimant reported the following side effects from the medication(s):

Please list medications for the industrial condition(s), if any?
Is there a reasonable medical probability that claimant will experience side effectsfrom the industrial medication(s)?
Yes No Other:
What side effect(s) are likely to occur, if any?
Sweating / Dry Mouth
Weight Loss / Depression
Drowsiness / Feeling weak
Difficulty maintaining concentration / Dizziness
Reduced short term memory / Confusion
Constipation / Low Energy
Mental/Mood Changes / Headaches
Blurry Vision / Trouble Sleeping
Nausea / Loss of Appetite / Other
Vomiting / Diarrhea / Other
Sedation / Weight Gain / Other
Will the claimant experience fatigue due to the side effects from the medication? / YES / NO
Please list medications for non-industrial condition(s), if any?
Is there a reasonable medical probability the claimant will experience side effects from non-industrial medication(s), if any?
Yes No If yes, please explain:
Degrees of Functional Limitations defined:
1. None means no impairment is noted in the functions.
2. Mild implies that any discerned impairment is compatible with most useful functioning.
3. Moderate means that the identified impairments are compatible with some, but not all, useful functioning.
4. Marked is a level of impairment that significantly impedes useful functioning. Taken alone, a marked impairment would not completely preclude functioning, but together with marked limitation in another class, it might limit useful functioning.
If appropriate, please choose one of the following definitions of “off task” for “Moderate restriction” you feel best describes your patient’s loss of useful function expressed as percentile:

1. “Off task” 10% of the time over the course of an 8 hour day due to the side effects of medication;
2. “Off task” 15% of the time over the course of an 8 hour day due to the side effects of medication;
3. “Off task” 20% of the time over the course of an 8 hour day due to the side effects of medication;
4. “Off task” ____% of the time over the course of an 8 hour day due to the side effects of medication;

Assume that “off task” means an inability to perform the activity and/or a reduction in productivity over the course of an 8 hour work day.
To what degree will the side effects impair claimant’s ability for concentration, persistence pace separate and apart from the underlying industrial medical condition(s)?
None Mild Moderate Marked Other:
To what degree will the side effects impair claimant’s ability for concentration, persistence and pace in combination with the underlying industrial medical condition(s)?
None Mild Moderate Marked Other:
When side effects exist can you estimate the severity?
None Mild Moderate Marked Other::
Hours / <1 / 2 / 3 / 4 / 5 / 6 / Other:
Approximate duration of the most severe side effect(s):
Is claimant allowed to operate machinery or motorized vehicles when experiencing side effects from the medication? Yes No Other:
Is there a reasonable medical probability that the side effects will reduce claimant’s ability to perform work to a minimum standard of productivity while working? If yes, to what degree:
None Mild Moderate Marked Other:
Is there a reasonable medical probability that the side effects will reduce claimant’s ability to perform detailed work requiring hand/eye coordination? If yes, to what degree:
None Mild Moderate Marked Other:
Is there a reasonable medical probability that the side effects will reduce claimant’s cognitive acuity and/or ability to focus on activities such as reading, writing, computer use? If yes, to what degree:
None Mild Moderate Marked Other:
Is there a reasonable medical probabilityclaimant’sfatigue, if any, due to the combined effects of his or her medical condition(s), will reduce his or her exertional capacity to sit, stand, walk, lift, carry, push and/or pull?
Yes No Other:

I declare under penalty of perjury that the information contained in this report and its attachments, if any, is true and correct to the best of my knowledge and belief, except as to information that I have indicated I received from others. As to that information, I declare under penalty of perjury that the report accurately describes the information provided to me and except as noted herein, that I believe it to be true. I also declare under the perjury that this physician has no violated section 139.3 of the Labor Code.

My opinions are expressed to a degree of medical probability, unless otherwise stated.

Signature of Physician ______Date

Additional Comments:

EXAMPLES OF MEDCATIONS AND THE POTENTIAL SIDE EFFECTS AS REPORTED BY WebMD at:

Adderall; Ambien; Amitriptyline; Amoxicillin; Atenolol; Ativan; Bentyl; Celexa; Cephalexin; Clonazepam; Clonidine; Cymbalta; Diazepam; Dilaudid; Ditropan ; Effexor; Famotidine;Fentanyl; Flexeril; Furosemide; Gabapentin; Hydrochlorothiazide; Hydrocodone; Hydromorphone; Kadian; Klonopin; Lactulose; Lasix; Levitra; Lexapro; Lidoderm; Lipitor; Lisinopril; Lodine; Lorazepam; Lyrica; Metformin; Methadone; Methocarbamol; Metoprolol; Minoxidil;Mobic; Morphine; Neurontin; Naproxen; Nifedical;Niravam; Nizatidine; Norco; Norvasc; Omeprazole (Prilosec); Opana; Oxycodone; OxyContin; Paroxetine; Paxil; Percocet; Phentermine; Polyethylene Glycol; Potassium; Prednisone; Protonix; Prozac; Ritalin; Senna with Docusate Sodium; Seroquel; Sertraline; Skelaxin; Soma;Spironolactone; Testim;Tizanidine;Topamax; Topical Corticosteroids for Atopic Dermatitis;Tramadol; Trazodone; Ultram; Valium; Vicodin; Wellbutrin; Xanax; Zoloft

Medication / Side Effects
Adderall / Common side effects: Chronic Trouble Sleeping; Nervous; Easily Angered or Annoyed; False Sense of Well-Being. Infrequent side effects: Blurred Vision; Dry Mouth; Incomplete or Infrequent Bowel Movements; Inability to have an Erection; Dizzy; Excessive Sweating; Taste Problems; Loss of Appetite; Weight Loss; Head Pain; Fast Heartbeat; Heart Throbbing or Pounding; Feel like Throwing Up; Throwing Up; diarrhea; Stomach Cramps; Feeling Weak; Sexual Problems; Altered Interest in Having Sexual Intercourse.
Ambien / Common side effects: Hiccups. Infrequent side effects: Nightmares; Double Vision; Problems with Eyesight; Dry mouth; Indigestion; Urinary Tract Infection; Joint Pain; Muscle Pain; Drowsiness; Loss of Memory; Sensation of Spinning or Whirling; Dizzy; Head Pain; Feel Like Throwing Up; Throwing Up; Diarrhea; Stomach Cramps; Feeling Weak; Not Feeling Well.
Amitriptyline / Common side effects: Dry Mouth; Drowsiness; Dizzy; Taste Problems; Weight Gain; Increased Hunger; Head Pain. Infrequent side effects: Incomplete or Infrequent Bowel Movements; Chronic Trouble Sleeping; Excessive Sweating; Throwing Up; Heartburn; Diarrhea.
Amoxicillin / Common side effects: Head Pain; Thrush; Yeast Infection of Vagina or Vulva; Feel Like Throwing Up; Throwing Up; Diarrhea. Infrequent side effects: Itching; Stomach Cramps.
Atenolol / Common side effects: Drowsiness; Chronic Trouble Sleeping; Low Energy; Feeling Weak; Sexual Problems. Infrequent side effects: Stuffy Nose; Incomplete or Infrequent Bowel Movements; Feel Like Throwing Up; Throwing Up; Diarrhea; Stomach Cramps; Nervous; Anxious.
Ativan / Common side effects: Drowsiness; Dizzy; Slurred Speech. Infrequent side effects: Low Energy; Uncoordinated; Feeling Weak.
Bentyl / Common side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Decreased Sweating. Infrequent side effects: Blurred Vision; Dilated Pupil; Decreased Breast Milk Production; Drowsiness.
Celexa / Common side effects: Inability to have an Erection; Sexual Problems; Altered Interest in Having Sexual Intercourse; Problem with Ejaculation; Dry Mouth; Drowsiness; Chronic Trouble Sleeping; Feel Like Throwing Up. Infrequent side effects: Feeling Restless; Blurred Vision; Problem with Periods; Itching; Loss of Memory; Fever; Rash; Trouble Breathing; Excess Urination; Confused; Grinding of the Teeth; Blood Pressure Drop Upon Standing; Inflammation of the Nose; Sinus Irritation and Congestion; Increased Production of Saliva; Indigestion; Joint Pain; Muscle Pain; Low Energy; Excessive Sweating; Involuntary Quivering; Taste Problems; Loss of Appetite; Weight Gain; Weight Loss; Yawning; Throwing Up; Gas; Diarrhea; Stomach Cramps; Numbness and Tingling; Feeling Weak; Anxious.
Cephalexin / Common side effects: Yeast Infection of Vagina and Vulva; Diarrhea. Infrequent side effects: Thrush; Feeling Like Throwing Up; Throwing Up; Stomach Cramps.
Clonazepam / Common side effects:Drowsiness; Dizzy; Slurred Speech. Infrequent side effects:Depression; Muscle Weakness; Confused; Low Energy; Uncoordinated; Feeling Weak
Clonidine / Common side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Drowsiness; Dizzy; Low Energy; Feeling Weak. Infrequent side effects: Dry eye; Eye Irritation; Eye Itching; Blood Pressure Drop Upon Standing; Inability to have an Erection; Loss of Appetite; Feeling Like Throwing Up; Throwing Up; Nervous; Sexual Problems.
Cymbalta / Common side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Drowsiness; Dizzy; Chronic Trouble Sleeping; Low Energy; Excessive Sweating; Loss of Appetite; feel Like Throwing Up; Diarrhea. Infrequent side effects: Orgasm Problems; Blurred Vision; Itching; Hair Loss; Acne; Cramps; Involuntary Quivering; Temporary Redness of Face and Neck; Weight Loss; Throwing Up; Difficult or Pain Urination; Anxious; Problem with Ejaculation.
Diazepam / Common side effects: Drowsiness; Dizzy; Slurred Speech. Infrequent side effects: Low Energy; Uncoordinated; Feeling Weak.
Dilaudid / Common side effects: Abnormally Low Blood Pressure; Drowsiness; Feeling Faint; Dizzy; Loss of Appetite; Feeling Weak; Not Feeling Well. Infrequent side effects: Slow Heartbeat; Vocal Cord Swelling; A Spasm of the Larynx; Collapsed Portion of Lung; Significant Decrease in Lung Function; Bronchospasm; Fast Heartbeat; Change in Pulse; Involuntary Muscle Movements; Confused; Double Vision; Blurred Vision; Problems with Eyesight; Dry Mouth; Irritation of the Stomach or Intestines; Incomplete or Infrequent Bowel Movements; Spasm of a Bile Duct Tract; Spasm of the Ureter or Tube Connecting Kidney to Bladder; Head Pain; Feel Like Throwing Up; Throwing Up; Kidney Problems Causing a Decreased Amount of Urine to be Passed; Nervous; False Sense of Well-Being.
Ditropan / Common side effects: Dryness of the Nose; Dry Mouth; Incomplete or Infrequent Bowel Movements; Decreased Sweating; Drowsiness; Throat Dryness; Feel Like Throwing Up. Infrequent side effects: Urinary Tract Infection; Blurred Vision; Dry Eye; Inflammation of the Nose; Indigestion; Backache; Dizzy; Flu-Like Symptoms; Pain; Diarrhea; Difficult or Painful Urination; Stomach Cramps.
Doxazosin / Common side effects: Sensation of Spinning or Whirling; Dizzy; Low Energy; Head Pain. Infrequent side effects: Abnormal Heart Rhythm; Blood Pressure Drop Upon Standing; Fluid Retention in the Legs, Feet, Arms or Hands; Fast Heartbeat; Heart Throbbing or Pounding; Trouble Breathing; Inflammation of the Nose; Drowsiness; Feel Like Throwing Up; Nervous; Easily Angered or Annoyed.
Effexor XR / Common side effects: Nightmares; Inflammation of the Nose; Dry Mouth; Indigestion; Incomplete or Infrequent Bowel Movements; Drowsiness; Dizzy; Chronic Trouble Sleeping; Excessive Sweating; Chills; Involuntary Quivering; Taste Problems; Loss of Appetite; Weight Loss; Feel Like Throwing Up; Throwing Up; Gas; Diarrhea; Stomach Cramps; Nervous; Numbness and Tingling; Feeling Weak; Anxious. Infrequent side effects: Neck Pain; Twitching; Visible Water Retention; Weight Gain.
Famotidine / Common side effects: Head Pain. Infrequent side effects: Incomplete or Infrequent Bowel Movements; Diarrhea.
Fentanyl Patch / Common side effects: Hallucination; Fever; Periods of Not Breathing; Trouble Breathing; Cannot Empty Bladder; Abnormal Nervous System Function Affecting Mental Alertness; Dry Mouth; Conditions of Excess Stomach Acid Secretion; Incomplete or Infrequent Bowel Movements; Itching; Drowsiness; Dizzy; Excessive Sweating; Loss of Appetite; Head Pain; Feel Like Throwing Up; Throwing Up; Diarrhea; Stomach Cramps; Nervous; Feeling Weak; Confused; Anxious; False Sense of Well-Being. Infrequent side effects: Depression; Unsteady Walking; Abnormal Heart Rhythm; Abnormally Low Blood Pressure; Acute Infection of the Nose, Throat or Sinus; Significant Decrease in Lung Function; Feeling Faint; Voluntary Movement Difficulty; Slurred Speech; Coughing Up Blood; Chest Pain; Signs and Symptoms at Injection Site; Paranoia; Nightmares; Feeling Restless; Stinging of Skin; Throat Irritation; Loss of Memory; Low Energy; Flu-Like Symptoms; Bloating.
Flexeril / Common side effects: Blurred Vision; Dry Mouth; Drowsiness; Dizzy.
Furosemide / Common side effects: Blood Pressure Drop Upon Standing. Infrequent side effects: Low Amount of Magnesium in the Blood; Low Amount of Calcium in the Blood; Low Amount of Sodium in the Blood; Low Amount of Potassium in the Blood; Imbalance in Body Salts like Potassium and Sodium; Low Amount of Chloride in the Blood; Blurred Vision; Dry Mouth; Sun-Sensitive Skin; Cramps; Drowsiness; Dizzy; Loss of Appetite; Head Pain; Diarrhea; Stomach Cramps.
Gabapentin / Common side effects: Double Vision; Blurred Vision; Problems with Eyesight; Muscle Pain; Drowsiness; Dizzy; Low Energy; Involuntary Quivering; Fluid Retention in the Legs, Feet, Arms or Hands.
Hydrochlorothiazide / Infrequent side effects: Blood Pressure Drop Upon Standing; Sun-Sensitive Skin; Loss of Appetite; Diarrhea; Stomach Cramps; Sexual Problems.
Hydrocodone Compound Oral / Common side effects: lightheadedness, dizziness, drowsiness, vision changes, vomiting, and constipation.
Hydromorphone / Common side effects: Abnormally Low Blood Pressure; Drowsiness; Feeling Faint; Dizzy; Loss of Appetite; Feeling Weak; Not Feeling Well. Infrequent side effects: Slow Heartbeat; Vocal Cord Swelling; A Spasm of the Larynx; Collapsed Portion of Lung; Significant Decrease in Lung Function; Bronchospasm; Fast Heartbeat; Change in Pulse; Involuntary Muscle Movements; Confused; Double Vision; Blurred Vision; Problems with Eyesight; Dry Mouth; Irritation of the Stomach or Intestines; Incomplete or Infrequent Bowel Movements; Spasm of a Bile Duct Tract; Spasm of the Ureter or Tube Connecting Kidney to Bladder; Head Pain; Feel Like Throwing Up; Throwing Up; Kidney Problems Causing a Decreased Amount of Urine to be; Passed; Nervous; False Sense of Well-Being.
Kadian / Common side effects: Abnormally Low Blood Pressure; Incomplete or Infrequent Bowel Movements; Drowsiness; Feeling Faint; Dizzy; Feel Like Throwing Up; Throwing Up. Infrequent side effects: Slow Heartbeat; Vocal Cord Swelling; A Spasm of the Larynx; Collapsed Portion of Lung; Significant Decrease in Lung Function; Bronchospasm; Inflammation of Skin caused by an Allergy; Itching; Hives; Rash; Fast Heartbeat; Change in Pulse; Trouble Breathing; Giant Hives; Reaction due to an Allergy; Involuntary Muscle Movements; Confused; Double Vision; Blurred Vision; Problems with Eyesight; Dry Mouth; Irritation of the Stomach or Intestines; Spasm of a Bile Duct Tract; Spasm of the Ureter or Tube Connecting Kidney to Bladder; Loss of Appetite; Head Pain; Kidney Problems Causing a Decreased Amount of Urine to be Passed; Nervous; Feeling Weak; Not Feeling Well; False Sense of Well-Being.
Klonopin / Common side effects: Drowsiness; Dizzy; Slurred Speech. Infrequent side effects: Low Energy; Uncoordinated; Feeling Weak.
Lactulose / Infrequent side effects: Excessive Thirst; Gas; Diarrhea; Stomach Cramps.
Lasix / Common side effects: Blood Pressure Drop Upon Standing Infrequent side effects: Low Amount of Sodium in the Blood; Low Amount of Potassium in the Blood; Imbalance in Body Salts like Potassium and Sodium; Low Amount of Chloride in the Blood; Blurred Vision; Sun-Sensitive Skin; Loss of Appetite; Head Pain; Diarrhea; Stomach Cramps.
Levitra / Common side effects: Inflammation of the Nose; Indigestion; Temporary Redness of Face and Neck; Head Pain. Infrequent side effects: Backache; Sinus Irritation and Congestion; Dizzy; Flu-Like Symptoms; Feel Like Throwing Up.
Lexapro / Common side effects: Dry Mouth; Conditions of Excess Stomach Acid Secretion; Incomplete or Infrequent Bowel Movements; Inability to have an Erection; Drowsiness; Dizzy; Chronic Trouble Sleeping; Low Energy; Excessive Sweating; Feel Like Throwing Up; Diarrhea; Altered Interest in Having Sexual Intercourse; Problem with Ejaculation. Infrequent side effects: Inflammation of the Nose; Sinus Irritation and Congestion; Flu-Like Symptoms; Loss of Appetite; Stomach Cramps; Sexual Problems.
Lidoderm / Common side effects: Complication at Treatment Site.
Lipitor / Common side effects: Indigestion; Incomplete or Infrequent Bowel Movements; Gas; Stomach Cramps. Infrequent side effects: Throat Irritation; Sinus Irritation and Congestion; Dizzy; Flu-Like Symptoms; Rash; Head Pain; Feel Like Throwing Up; Diarrhea.
Lisinopril / Common side effects: Head Pain; Cough. Infrequent side effects: Acute Infection of the Nose, Throat or Sinus; Stuffy Nose; Indigestion; Inability to have an Erection; Cramps; Sensation of Spinning or Whirling; Low Energy; Taste Problems; Feel Like Throwing Up; Throwing Up; Diarrhea; Numbness and Tingling; Feeling Weak; Altered Interest in Having Sexual Intercourse.
Lodine / Common side effects: Conditions of Excess Stomach Acid Secretion; Dizzy; Low Energy; Head Pain; Feel Like Throwing Up; Gas; Diarrhea; Stomach Cramps. Infrequent side effects: Depression; Double Vision; Blurred Vision; Problems with Eyesight; Ringing in the Ears; Ulcers of Esophagus; Stomach Ulcer; Ulcer from Stomach Acid; Stomach or Intestinal Ulcer; Burning Stomach; Red Blood in Bowel Movement; Bleeding of the Stomach or Intestines; Itching; Mental Impairment; Fever; Rash; Throwing Up Blood; Difficult or Painful Urination; Frequent Urination; Mood Changes; Incomplete or Infrequent Bowel Movements; Bloating; Nervous; Easily Angered or Annoyed.
Lorazepam / Common side effects: Drowsiness; Dizzy; Slurred Speech. Infrequent side effects: Low Energy; Uncoordinated; Feeling Weak.
Lyrica / Common side effects: Dizzy. Infrequent side effects: Dry Mouth; Incomplete or Infrequent Bowel Movements; Pain; Head Pain; Injury; Feeling Weak.
Metformin / Common side effects: Acute Infection of the Nose, Throat or Sinus; Taste Problems; Loss of Appetite; Weight Loss; Head Pain; Feel Like Throwing Up; Throwing Up; Gas; Bloating; Diarrhea; Stomach C ramps. Infrequent side effects: Inflammation of the Nose; Indigestion; Incomplete or Infrequent Bowel Movements; Dizzy.