| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
Dear Doctor: In addition to the information provided in your narrative report, please complete Items 1 through 12 by circling the appropriate word and items 13 through 17 by filling in the blank. It is essential that your answers be based on your estimate of claimant's current psychiatric impairment and not on non-medical factors, such as availability of job openings or hiring practices of employers. However, it is also essential that the assessment be of ability to perform these activities over a sustained period of time in a full or part time work setting. |
Please indicate Degree of Limitation based on the following definitions: | |
NONE: | No impairment in this area. |
| SLIGHT: | Suspected impairment which marginally affects ability to function. |
| MODERATE: | Impairment which imposes more than marginal, but less than serious affect on the abililty to function. |
| MARKED: | An impairment which seriously affects ability to function. |
| EXTREME: | Extreme impairment of ability to function over a sustained period of time. |
| UNKNOWN: | Insufficient evidence. |
| The patient's sustained ability in an 8 hour workday, 5 days a week, to: | |||||||
1. | Understand, remember, and carry out an extensive variety of technical and/or complex job instructions: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
2. | Understand, remember, and carry out detailed but uncomplicated job instructions: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
3. | Understand, remember, and carry out simple one or two-step job instructions (assess all three cumulatively): | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
4. | Interact appropriately with supervisors and supervisory demands in a competitive job setting: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
5. | Interact appropriately with co-workers in a competitive job setting: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
6. | Deal appropriately with the public: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
7. | Maintain sustained concentration and attention: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
8. | Respond appropriately to customary work pressures five days a week in a routine work setting: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
9. | Care appropriately for his/her own grooming and hygiene: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
10. | Perform adaptive activities such as cleaning and cooking: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
11. | Initiate and participate in activities required for daily living outside the home, (e.g. going shopping, using a post office, or taking public transportation): | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
12. | Travel unaccompanied outside of one's immediate living: | ||||||
| NONE | SLIGHT | MODERATE | MARKED | EXTREME | UNKNOWN | ||
13. | Is the patient's mental status likely to result in decompensation under the stress of a competitive full time job in a non-sheltered environment? Yes ______ No ______ If yes, please explain: | ||||||
14. | If the patient suffers from substance abuse or addiction (alcohol or drugs), will he/she be able to control or refrain from the use of the substance while working at a competitive non-sheltered job? Yes ______ No ______ If no, please explain: | ||||||
15. | In each question above marked "unknown", state what evidence or tests could provide this data: | ||||||
16. | Duration of impairment: Will the limitation listed above last for 12 months or longer? Yes ______ No ______ If the limitations already have lasted for over 13 months, when did these limitations begin? | ||||||
17. | Has there been a diagnosis of the patient's impairment? Yes ______ No ______ If yes, give the DSM-III classification: | ||||||
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |