Lee Ann Torrans Social Security Strategy

Name: __________________________ Social Security No. ________________________

Please answer the following questions concerning your patient's impairments.

1. Frequency and length of contact: ______________________________________________________
___________________________________________________________________________________________

2. DSM-IV Multitaxial Evaluation:

Axis I _____________________________ Axis IV: _____________________________________
Axis II ____________________________ Axis V: Current GAF: _________________________
Axis III ___________________________ Highest GAF past year: ________________________

3. Identify your patient's signs and symptoms:

a. Poor memory ______
b. Appetite disturbance with weight change ______
c. Sleep disturbance ______
d. Personality change ______
e. Mood disturbance ______
f. Emotional lability ______
g. Loss of intellectual ability of 15 IQ points or more ______
h. Delusions or hallucinations ______
i. Substance dependence ______
j. Recurrent panic attacks ______
k. Anhedonia or pervasive loss of interests ______
l. Psychomotor agitation or retardation ______
m. Paranoia or inappropriate suspiciousness ______
n. Feelings of guilt/worthlessness ______
o. Difficulty thinking or concentrating ______
p. Suicidal ideation or attempts ______
q. Oddities of thought, perception, speech or behavior ______
r. Perceptual disturbances ______
s. Time or place disorientation ______
t. Catatonia or grossly disorganized behavior ______
u. Social withdrawal or isolation ______
v. Blunt, flat or inappropriate affect ______
w. Illogical thinking or loosening of associations ______
x. Decreased energy ______
y. Manic syndrome ______
z. Obsessions or compulsions ______
aa. Intrusive recollections of a traumatic experience ______
bb. Persistent irrational fears ______
cc. Generalized persistent anxiety ______
dd. Somatization unexplained by organic disturbance ______
ee. Hostility and irritability ______
ff. Pathological dependence or passivity ______

Other symptoms and remarks: _______________________________________________________
___________________________________________________________________________________

4. Describe the clinical findings including results of mental status examination
which demonstrate the severity of your patient's mental impairment and symptoms:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

5. Are your patient's impairments reasonably consistent with the symptoms and
functional limitations described in this evaluation? ______ Yes ______ No

If no, please explain: ____________________________________________________________________
_______________________________________________________________________________________

6. a. List prescribed medication and dosage Daily Amount Taken
__________________________________ ___________________________
__________________________________ ___________________________
__________________________________ ____________________________
__________________________________ ____________________________

b. Describe any side effects of medications which may have implications for
working, e.g.
dizziness, drowsiness, fatigue, lethargy, stomach upset, etc: __________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

7. Does your patient have a low I.Q. or reduced intellectual functioning?
______ Yes ______ No

Please explain (with reference to specific test results): ________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

8. On the average, how often do you anticipate that your patient's impairments
or treatment would cause your patient to be absent from work?

___Never ___ Less than once a month ___ About once a month
___ About twice a month ___ About three times a month ___ More than 3 times
a month

Independent of any impairment from alcoholism and/or drug addiction, please
rate the
individual's capabilities to perform the following basic mental activities of
work on a
regular and continuing basis. "Regular and continuing basis" means
8 hours a day for 5 days a week or an equivalent work schedule.

No/mild loss No significant loss of ability in the named activity; can sustain
performance for 2/3 or more of an 8-hour workday.

Moderate loss Some loss of ability in the named activity but still can sustain
performance for 1/3 up to 2/3 of an 8-hour workday.

Marked loss substantial loss of ability in the named activity; can sustain
performance only up to 1/3 of an 8-hour workday.

Extreme loss Complete loss of ability in the named activity; can not sustain
performance during an 8-hour workday.

9. Is ability to understand, remember and carry out instructions affected by
the impairment?
_____Yes _____No
If "no", go to next question. If "yes", please check the
appropriate block to described the individual's ability to perform the following
work-related mental activities:

No/mild Moderate Marked Extreme
Loss Loss Loss Loss

a. Remember locations and work-like procedures _______ _______ _______ ______

b. Understand and remember very short,
simple instructions. _______ ________ _______ _______

c. Carry out very short, simple instructions ______ ________ _______ _______

d. Understand and remember detailed instructions ______ ________ ________ ________

e. Carry out detailed instructions _______ ________ ________ _________

f. Maintain attention and concentration
for extended periods, i.e. 2 hour segments ______ ________ ________ ________

g. Maintain regular attendance and be punctual ______ _______ ________ ________

h. Sustain an ordinary routine without special
supervision. _______ _______ ________ _______

i. Deal with stress of semi-skilled and
skilled work _______ ________ ________ ________

j. Work in coordination with or proximity
to others without being unduly distracted _______ ________ _________ _______

k. Make simple work-related decisions. _______ ________ _________ _______

l. Complete a normal workday or workweek
without interruptions from psychologically
based symptoms _______ ________ _________ _______

m. Perform at a consistent pace without an
unreasonable number and length of rest periods ___ ________ _________ _______

10. Is ability to respond appropriately to supervision, coworkers and work pressure
in a work-setting affected by the impairment? If "no", go to next
question. If "yes", please check the appropriate block to describe
the individual's ability to perform the following work-related mental activities.

______ Yes ______ No

No/Mild Moderate Marked Extreme
Loss Loss Loss Loss

a. Interact appropriately with the public _______ _______ ______ _______

b. Ask simple questions or request assistance. _______ ________ _____ _______

c. Accept instructions and respond appropriately
to criticism from supervisors. _______ ________ _________ _______

d. Get along with coworkers and peers
without unduly distracting them or exhibiting
behavioral extremes. _______ ________ _________ _______

e. Maintain socially appropriate behavior _______ ________ _________ _______

f. Adhere to basic standards of neatness and
cleanliness. _______ ________ _________ _______

g. Respond appropriately to changes in a
routine work setting _______ ________ _________ _______

h. Be aware of normal hazards and take
appropriate precautions _______ ________ _________ _______

i. Travel in unfamiliar places _______ _________ _________ ________

j. Use public transportation _______ ________ _________ _______

k. Set realistic goals or make plans
independently of others _______ ________ _________ _______

11. Indicate to what degree the following functional limitations exist as a
result of your patient's mental impairments.

FUNCTIONAL LIMITATION DEGREE OF LIMITATION

a. Restriction of activities of daily living: None _ Slight __ Moderate __Marked
* __ Extreme __

b. Difficulties in maintaining social
functioning: None __ Slight __ Moderate __ Marked ___ Extreme ___

c. Deficiencies of concentration,
persistent or pace resulting in
failure to complete tasks in a
timely manner (in work settings
or elsewhere) Never __ Seldom __ Often __ Frequent ___ Constant ___

d. Episodes of deterioration or
decompensation in work or work-
like settings which cause the
individual to withdraw from that
situation or to experience exacerbation
of signs and symptoms (which may
include deterioration of adaptive
behaviors) Never ___ Once or Twice ___ Repeated ___ Continual ___

*Note: Marked means more than moderate, but less than extreme. A marked limitation
may arise when several activities or functions are impaired or even when only
one is impaired, so long as the degree of limitation is such as to seriously
interfere with the ability to function independently, appropriately and effectively.

12 . Can your patient manage benefits in his or her own best interest? ____
Yes _____ No

13. PERIOD OF RESTRICTION: Has the individual's condition existed and persisted
with the restrictions as outlined in this Medical Source Statement at least
since ______________?

____ Yes ____ No

If not, state the first date the patient's condition existed and persisted
with
such restrictions.

______________________________

CERTIFICATION

By my signature appended hereto, I attest that I have answered truthfully and
accurately to the best of my ability, each of the questions presented in this
Medical Source Statement rating the individual's capabilities independent of
any impairment from alcoholism and/or drug addiction.

Dated _____________________________

______________________________
Signature

______________________________
Printed Name

______________________________
Address

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