| 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 a psychological or psychiatric impairment? Yes ______ No _______ | ||||||||||||||||||||||||||
| A. | What is the current diagnosis? Use DSM II, if applicable: | ||||||||||||||||||||||||||
| B. | On what date was the diagnosis first made? ________________ | ||||||||||||||||||||||||||
C. | What is the date of onset, if different? _________________ | ||||||||||||||||||||||||||
D. | How long have you been treating the condition? ________________ | ||||||||||||||||||||||||||
E. | What is the date of the most recent examination? ________________ | ||||||||||||||||||||||||||
2. | Has the patient ever undergone psychological testing? Yes ______ No _______ If so, please indicate that test given and the results (including sub-test scores where applicable):
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| 3. | Please circle as many of the recurring clinical manifestations/symptoms as are applicable to this patient. | ||||||||||||||||||||||||||
| A. | Organic Mental Disorders (Brain Dysfuntions) | ||||||||||||||||||||||||||
| Time/place disorientation | |||||||||||||||||||||||||||
| Memory impairment | |||||||||||||||||||||||||||
| Perceptual or thinking disturbances | |||||||||||||||||||||||||||
| Mood disturbance | |||||||||||||||||||||||||||
| Emotional disturbance | |||||||||||||||||||||||||||
| Emotional lability | |||||||||||||||||||||||||||
| Impulse control impairment | |||||||||||||||||||||||||||
| Loss of measured intelligence of at least 15 I.Q. points | |||||||||||||||||||||||||||
B. | Psychotic Disorders (Schizophenia, Paranoia, etc.) | ||||||||||||||||||||||||||
| Delusions | |||||||||||||||||||||||||||
| Hallucinations | |||||||||||||||||||||||||||
| Grossly disorganized behavior | |||||||||||||||||||||||||||
| Catatonia | |||||||||||||||||||||||||||
| Blunt affect | |||||||||||||||||||||||||||
| Flat affect | |||||||||||||||||||||||||||
| Incoherence | |||||||||||||||||||||||||||
| Loosening of associations | |||||||||||||||||||||||||||
| Illogical thinking | |||||||||||||||||||||||||||
| Emotional withdrawal | |||||||||||||||||||||||||||
| Emotional isolation | |||||||||||||||||||||||||||
C. | Affective Disorders (Mood Disturbances)
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D. | Anxiety Related Disorders | ||||||||||||||||||||||||||
| Motor tension | |||||||||||||||||||||||||||
| Automatic hyperactivity | |||||||||||||||||||||||||||
| Apprehensive expectation | |||||||||||||||||||||||||||
| Vigilance and scanning | |||||||||||||||||||||||||||
| Agoraphobia | |||||||||||||||||||||||||||
| Irrational fears and avoidance of an object, activity, or situation | |||||||||||||||||||||||||||
| Weekly, severe panic attacks | |||||||||||||||||||||||||||
| Recurrent obsessions of compulsions | |||||||||||||||||||||||||||
| Recurrent, intrusive recall of traumas | |||||||||||||||||||||||||||
E. | Somatoform Disorders | ||||||||||||||||||||||||||
| Persistent non-organic disturbance of (select one): | |||||||||||||||||||||||||||
| vision | hearing | ||||||||||||||||||||||||||
| speech | use of limb | ||||||||||||||||||||||||||
| other (e.g. psychogenic seizures) | |||||||||||||||||||||||||||
OR | |||||||||||||||||||||||||||
| Exaggerated interpretation of physical signs. | |||||||||||||||||||||||||||
OR | |||||||||||||||||||||||||||
| Pain and preoccupation with a disease. | |||||||||||||||||||||||||||
F. | Personality Disorders | ||||||||||||||||||||||||||
| Seclusiveness | Pathological dependence | ||||||||||||||||||||||||||
| Autistic thinking | Pathological passivity | ||||||||||||||||||||||||||
| Pathological suspicion | Pathological hostility | ||||||||||||||||||||||||||
| Pathological aggressiveness | |||||||||||||||||||||||||||
| Oddities of thought, perception, speech and behavior. | |||||||||||||||||||||||||||
| Unstable interpersonal relationship with damaging behavior. | |||||||||||||||||||||||||||
G. | Mental Retardation and Autism Disorders | ||||||||||||||||||||||||||
| Dependence on others for personal needs. | |||||||||||||||||||||||||||
| Deficit in social and communicative skills. | |||||||||||||||||||||||||||
| I.Q. less than 99. | |||||||||||||||||||||||||||
| I.Q. 60 and 69, inclusive. | |||||||||||||||||||||||||||
| 4. | Are there certain situations which "cause" or "trigger" the symptoms noted in 3? If so, please describe them briefly on a separate sheet or narrative report. | ||||||||||||||||||||||||||
| ____________________ | Encounter with other people | ||||||||||||||||||||||||||
| ____________________ | Encounter with groups of people | ||||||||||||||||||||||||||
| ____________________ | Parties or other Social Functions | ||||||||||||||||||||||||||
| ____________________ | Work setting | ||||||||||||||||||||||||||
| ____________________ | At Home with Family | ||||||||||||||||||||||||||
| ____________________ | At School | ||||||||||||||||||||||||||
| ____________________ | Travel | ||||||||||||||||||||||||||
| ____________________ | Other - Please Identify | ||||||||||||||||||||||||||
5. | Does this illness restrict daily activities? Yes _____ No _____. If yes, please explain: | ||||||||||||||||||||||||||
| 6. | Does this illness cause any marked differences in maintaining social functioning? Yes _____ No _____ If yes, please describe: | ||||||||||||||||||||||||||
| 7. | Has this illness caused deficiencies of concentration and of persistence resulting in frequent failure to complete tasks? Yes _____ No _____. If yes, please describe (include work setting examples): | ||||||||||||||||||||||||||
| 8. | Has this illness caused repeated episodes of deterioration or decompensation in work or worklike situations which require the individual to withdraw from that situation and/or to experience exacerbation of signs and symptoms? Yes _____ No _____. If so, please describe and state frequency: | ||||||||||||||||||||||||||
| 9. | Is this patient's living situation a highly structured and supportive setting? Yes _____ No _____. If not, does the patient need such a setting? Yes _____ No _____. If so, how will the patient function outside of this setting? | ||||||||||||||||||||||||||
| 10. | Is this patient's illness under control such that she/he is able to work in a non-sheltered work setting? Yes _____ No _____. If so, please explain: | ||||||||||||||||||||||||||
| 11. | Only answer #11 if patient is psychotic. Do you consider this patient able to work even when she/he is not actively psychotic? Yes _____ No _____. If so, please explain: | ||||||||||||||||||||||||||
| 12. | How is this patient treated for this illness? (Please indicate frequency and type of therapy; as well as name, strength, and frequency of medication): | ||||||||||||||||||||||||||
| 13. | What, if any, functional restrictions are caused by prescribed medication? | ||||||||||||||||||||||||||
| 14. | What has been the patient's response to treatment and what is your prognosis? | ||||||||||||||||||||||||||
| 15. | Other Comments: | ||||||||||||||||||||||||||
| 16. | From what other medical or psychological conditions does the patient suffer in addition to those described above? | ||||||||||||||||||||||||||
| 17. | Are you treating these conditions? Yes _____ No _____. | ||||||||||||||||||||||||||
| Date Report Completed: | ______________________________ |
| Signature of Physician: | ______________________________ |
| Physician Name: | ______________________________ |
| Address: | ______________________________ |
| Telephone: | ______________________________ |
| Specialty: | ______________________________ |