Physical Impairment Evidence Checklist worksheet
Use this checklist to organize imaging, tests, therapy, pain records, and mobility limits.
| Item | Your notes |
|---|---|
| Use This Checklist To Organize Imaging | ____________________________ |
| Tests | ____________________________ |
| Therapy | ____________________________ |
| Pain Records | ____________________________ |
| Mobility Limits | ____________________________ |
| Provider | ____________________________ |
| Dates of treatment | ____________________________ |
| Diagnosis or condition | ____________________________ |
| Key test or finding | ____________________________ |
| Treatment tried | ____________________________ |
| Medication or side effect | ____________________________ |
| Functional limitation | ____________________________ |
Before you use this checklist
- Copy dates and instructions from the current SSA notice rather than memory.
- Keep originals and work from copies.
- Do not send Social Security numbers, bank information, or full medical files to an unverified recipient.
- Save filing confirmations and proof of any time-sensitive submission.