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Patient Mental Impairment Report by Treating Source
Patient: _______________________ Mental Health Care Provider: ___________________
Patient Social Security #: ________________
Please provide the following information relating to your patient’s medical and mental health
conditions.
Date of first treatment and frequency of examination:
________________________________________________________________________
DSM-IV Multiaxial Evaluation
Axis I
___________________________
Axis IV _______________________
Axis II ___________________________
Axis V _______________________
Axis III ___________________________
Treatment:
________________________________________________________________________
________________________________________________________________________
Medications with notation of any side effects:
________________________________________________________________________
________________________________________________________________________
Prognosis:
________________________________________________________________________
Findings on mental status examination:
________________________________________________________________________
________________________________________________________________________
Signs and Symptoms
________________________________________________________________________
________________________________________________________________________
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Degree to which mental conditions affect patient’s ability to do work-related activities.
Consider this in terms of the patient’s ability to do work-related activities on a day-to-day basis
in a regular work setting. Please rate them in the following categories:
- No significant limitation means the patient would perform near normal when performing the
activity.
- Noticeable limitation means the patient’s deficiency would be noticeable even while retaining
some ability to perform the activity. It would be the equivalent of being in the bottom 15% of
the population in performance of the activity, or one standard deviation below the norm.
-Substantial loss of use means the patient cannot satisfactorily perform the activity
independently, effectively, or appropriately in a regular work setting. They would require a
sheltered work setting where special considerations and attention are provided to perform it, if
they could do it at all. It would be the equivalent of being in the bottom 3% of the population
in performance of the activity, or two or more standard deviations below the norm.
Mental Abilities
No
Noticeable Substantial
significant limitation loss of use
limitation
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remember locations and worklike procedures
2
3
understand, remember or carry out very short and
simple instructions
make simple work-related decisions
4
ask simple questions or request assistance
5
understand, remember, or carry out detailed
instructions
maintain concentration and attention for
extended periods (the approximately 2-hour
segments between arrival and first break, lunch,
second break, and departure).
perform activities within a schedule, maintain
regular attendance, and be punctual within
customary tolerances
sustain an ordinary routine without special
supervision
work in coordination with or proximity to others
without being unduly distracted by them
complete a normal workday/week without
interruptions from psychologically based
symptoms & perform at consistent pace without
unreasonable number and length of rest periods
6
7
8
9
10
2
11
14
be aware of normal hazards and take appropriate
precautions
accept instructions and respond appropriately to
criticism from supervisors
get along with coworkers or peers without unduly
distracting them or exhibiting behavioral extremes
maintain socially appropriate behavior
15
meet basic standards of neatness and cleanliness
16
respond appropriately to changes in a routine
work setting
12
13
Do your patient’s mental impairments ever cause intermittent symptoms or exacerbations
severe enough that they would cause him/her to need to take unscheduled work breaks during
a shift if he/she was at a full-time job?
____ Yes
____ No
If your answer is yes, then please state on average how often such breaks would be needed:
____ times every
____ minutes or ___ hours
and please state how long each such break would typically be
___ hours ____ minutes
Do your patient’s mental impairments ever cause intermittent symptoms or exacerbations
severe enough that they would cause him or her to take unscheduled days off work if they were
at a full-time job?
____ Yes
____ No
If yes, then how many days per month would the patient be absent from work on average?
____ less than 1 day ____ 1 day ____2 days ____ 3 days ____ More than 3 days
What is the earliest date the above level of limitation applies? _______________
Signature:
Date: _______________
____________________________
Print Name:
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