| PATIENT:_________________________________________________ | |||
| SOCIAL SECURITY #:_______________________________________ | |||
| DATE OF BIRTH:____________________________________________________ | |||
To the Doctor: Please complete the following report attaching copies of lab reports. Please use the back of the form if additional space is needed. |
| 1. | Does this patient suffer from any neurological impairment or disease? Yes ______ No ______ If yes: | ||||||||||||||||||||||||||||||||||||||
| A. | What is the current diagnosis? | ||||||||||||||||||||||||||||||||||||||
| B. | On what date was the diagnosis first made? | ||||||||||||||||||||||||||||||||||||||
| C. | What is the date of onset, if different? | ||||||||||||||||||||||||||||||||||||||
| D. | What is the most recent date of examination? | ||||||||||||||||||||||||||||||||||||||
| E. | At the time of the last examination what was the patient's height _______ weight _______? | ||||||||||||||||||||||||||||||||||||||
2. | Is paralysis or paresis present? Yes ________ No _________ If yes, please describe location and severity: | ||||||||||||||||||||||||||||||||||||||
| 3. | Please describe residual functional capacity in the patient's extremities: | ||||||||||||||||||||||||||||||||||||||
| A. | Upper extremities (check all that apply indicating % of function left)
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| 1) Are there allegations of pain? Yes ______ No ______ If yes, please describe: | |||||||||||||||||||||||||||||||||||||||
| 2) Is the degree of pain reasonably related to the underlying diagnosed condition? Yes ______ No ______ (If no, is there a medical or psychological explanation for the pain complained of?) | |||||||||||||||||||||||||||||||||||||||
| 3) Is there any loss of grip in hands? Yes ______ No ______ If yes, please describe: | |||||||||||||||||||||||||||||||||||||||
| B. | Lower extremities: | ||||||||||||||||||||||||||||||||||||||
| 1) Have there been any Conduction Studies performed? Yes _____ No ______ If yes, please give results: | |||||||||||||||||||||||||||||||||||||||
| 2) Straight leg raising results: | |||||||||||||||||||||||||||||||||||||||
| 3) Describe gait: | |||||||||||||||||||||||||||||||||||||||
| 4) Ambulation: Normal ______ Cane ______ Crutches ______ Wheelchair ______ Bedfast ______ | |||||||||||||||||||||||||||||||||||||||
| 5) Coordination of extremities: Poor ______ Fair ______ Good ______ No impairment ______ | |||||||||||||||||||||||||||||||||||||||
| C. | Is assistance in weight bearing needed? Yes ______ No ______ If yes, please describe: | ||||||||||||||||||||||||||||||||||||||
| 7. | Does patient have sensory or motor aphasia? Yes ______ No ______ If yes, please describe ability to communicate: | ||||||||||||||||||||||||||||||||||||||
| 8. | Indicate and describe presence and severity of any of the following:
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| 9. | Results of pertinent laboratory test with dates (such as EEG, CT scan, x-ray, etc.): TEST DATE RESULTS | ||||||||||||||||||||||||||||||||||||||
| 10. | Has the patient's mental status been affected by impairment(s)? Yes ______ No ______ If yes, please describe: | ||||||||||||||||||||||||||||||||||||||
| 11. | The patient's condition is: Improving ____ Stable ____ Deteriorating ____ Remarks: | ||||||||||||||||||||||||||||||||||||||
| 12. | What is the present therapy for the condition? | ||||||||||||||||||||||||||||||||||||||
| 13. | What has been the response to therapy? | ||||||||||||||||||||||||||||||||||||||
| 14. | What medications is the patient currently taking for the condition? | ||||||||||||||||||||||||||||||||||||||
| 15. | Are there any side effects from the medication observed or reported? Yes ______ No ______. If so, what are they? | ||||||||||||||||||||||||||||||||||||||
| 16. | Please note any other medical impairment that would restrict patient's ability to function? | ||||||||||||||||||||||||||||||||||||||
| 17. | Are you treating these other impairments? Yes _____ No ______ | ||||||||||||||||||||||||||||||||||||||
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |