ID:_________________ CF#:________________
Analyst: _________________________________

Date: _____/_____/2014
Claimant: ___________________________
SSN: _________-________-_________ ___-year-old,
__Right __Left __Ambidextrious
__Caus __ AA __Hispanic ____________
__Female - __Male
___________________DOB
__Able __Unable __CDL __Pic.ID ___________

__On Time __Early __Late
__Drove Brought by _________ Other:_________
__Interacted __inappropriately __
__ambulate assistance. _______________ __ __reliable __questionable __poor historian.

Primary language is (_English _Spanish _Hmong _Chinese _Vietnamese) and an interpreter (was - was not) used for this evaluation.

___There were no records.

SSA Form: __3368 __3373 __454
Co: __________________________________ prog.note/evaluation/_______________________ authored by ________________________ on ____/___/_____.
Co: __________________________________ prog.note/evaluation/_______________________ authored by ________________________ on ____/___/_____.
Co: __________________________________ prog.note/evaluation/_______________________ authored by ________________________ on ____/___/_____.
Co: __________________________________ prog.note/evaluation/_______________________ authored by ________________________ on ____/___/_____.

The claimant __reported __denied mental health symptoms of _________________________.

endorsed symptoms of depression since ___________________________________. current symptoms occur: __most days __daily __weekly __intermittently _______________ severity is in the __mild __mild to moderate __moderate __moderate to severe __severe range. Compared to when the symptoms first began, they are __better __worse __unchanged.

…current depressive symptoms include: __ __decreased concentration __loss of interest in prior activities, __ occasional/frequent thoughts of suicide __feelings of worthlessness __disturbed sleep patterns __Psychomotor retardation __Psychomotor agitation.

endorsed symptoms of anxiety since ________________________________________. current symptoms occur: __most days __daily __weekly __intermittently _________________ severity is in the __mild __mild to moderate __moderate __moderate to severe __severe range. Compared to when the symptoms first began, they are __better __worse __unchanged. …current anxiety symptoms include: __feeling restless __irritability __ __ __ __sits on edge of chair __ __inhibited movements __easy fatigability

endorsed symptoms of a panic attack since _______________________. current symptoms occur: __most days __daily __weekly __intermittently _________________ severity is in the __mild __mild to moderate __moderate __moderate to severe __severe range. Compared to when the symptoms first began, they are __better __worse __unchanged.

current panic symptoms include: __ __ __ ______sensations of shortness of breath __ hot flashes endorsed symptoms of anxiety since ________________________________________. current symptoms occur: __most days __daily __weekly __intermittently _________________ severity is in the __mild __mild to moderate __moderate __moderate to severe __severe range. Compared to when the symptoms first began, they are __better __worse __unchanged. current PTSD symptoms include:__

__ treatment
__did get treatment for the above described symptoms. Including: __________________________________________________________
__ a workman’s compensation claim for an injury at his place of employment in ____________.
__has not __has reached a settlement with Workman’s Compensation.

__ pain __Intermittent as a result of an injury in ______. “_______/10” without meds. pain level decreases to “______/10” with pain medication.
__Reports

CURRENT MED:
___is not ___is prescribed and reports medication compliance with the following medications:

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

MEDICAL CONDITIONS:
The claimant /reported a history of head trauma.

PAST PSYCHIATRIC HISTORY
The claimant reports having /a history of _____suicide attempt(s). He reported/ prior psychiatric hospitalizations. There is reportedly /a history of self-injurious behaviors. There is reportedly a/ history of being a danger to others. Claimant reports a/ history of being gravely disabled. He /reports current suicidal and homicidal ideation. He /reports receiving outpatient psychiatric treatment at this time.

PSYCHOSOCIAL HISTORY:
Personal History:
… born in ____________________, ____________/. and raised by his __________/ He is the ________oldest of ______/ children born to his mother. Developmental Delays were denied/reported. In utero exposure was /reported. He /reports a history of physical, sexual, verbal and emotional abuse. Overall, the claimant describes his childhood as “__________/.” The claimant a family history of mental illness. The claimant is a adult who has The claimant currently He current source of income is $ per month, from Funds are managed by .

Education:
He reported completing the grade and receive a high school diploma. He further education and/or specialized training. The claimant having a learning disability and being placed in special education.

Employment:
The claimant described his work history as . He was last employed at for He reported he left the job due in , secondary to . He reports, he got along with co-workers and supervisors.”

Military:
The claimant . served in the U.S. Military.

Substance Abuse:
The claimant a history of substance He reports . He reports having a marijuana license and smokes cannabis

Forensic:
The claimant reports prison terms and history of arrests. He currently on parole or probation.

ACTIVITIES OF DAILY LIVING:
He . having physical limitations due to medical problems. For transportation, the claimant He is /unable to make change at the store. His normal day begins at _________/ when he awakens. He /is not independent for basic self-grooming, completing light household chores and does not/does need help with preparing simple meals. During the day he _______________________________________________
__________________________________________________________________________
He goes to bed at _____________/ He describes his relationships with family as /bad/fair/distant/______________. He reports having /”bad”/distant/____________ relationships with friends. The claimant describes his support system as /bad/fair/________________.

MENTAL STATUS EXAMINATION:
GENERAL APPEARANCE:
The claimant appears /older/younger his stated age. His attire was _____
____________________/ as he wore______________________/ clothing. His grooming was /poor/fair. He presented in a /___________ manner and made ________/poor eye contact. Gross motor function was /impaired/agitated/slowed. Claimant interacted in/ with the examiner throughout the evaluation. No bizarre behavior was observed.

ATTITUDE AND BEHAVIOR:
The claimant was un/ with a ______________/ attitude.

THOUGHT PROCESSES/SPEECH:
The claimant's thought processes were His speech was of a tone, rate and rhythm, and

CONTENT OF THOUGHT:
The claimant's thought content was and He recent auditory or visual hallucinations. There suicidal, homicidal or paranoid ideation noted or reported during the interview. He appear to be responding to internal stimuli during the interview. There obvious signs of a thought disorder. MOOD/AFFECT:
The claimant's mood was with a affect. He any feeling of hopelessness, helplessness or worthlessness.

INTELLECTUAL FUNCTIONING/SENSORIUM:
The claimant is alert and oriented to He appears to be the average intelligence range. MEMORY:
Immediate: He was able to recall with digit span forward and backwards.

Recent: The claimant was to recall of three objects after five minutes of unrelated activities.

Remote: He was to give an account of his life events in a chronological order. FUND OF KNOWLEDGE/INFORMATION:
Consistent with his educational level and socioeconomic background. Fund of knowledge was He was to name Presidents of the United States, The claimant was to identify the capital of the United States as Washington D.C. He was to identify why the Fourth of July is celebrated.

CALCULATIONS:
The claimant /incorrectly stated that …80 cents. The claimant is /unable to do simple calculations such as 2+3-1 = 4, and how many quarters are in $2.25. The claimant could perform serial /with _____ errors.

CONCENTRATION:
His concentration was impaired/ He was /unable to spell 'world' forwards and backwards /with ______ error. He was /unable to follow a simple three step command with difficulty.

ABSTRACT THINKING:
The claimant's abstract thinking was impaired/ when asked to interpret the proverb, “You shouldn’t judge a book by its cover.” The claimant replies, “ .”

SIMILARITIES/DIFFERENCES:
The claimant was to differentiate appropriately. When asked the similarity between an apple and an orange he stated, “/____________ .” When asked the differences the claimant replied, “/__________________________

INSIGHT/JUDGMENT
Insight and judgment appear to be impaired/ regarding social situation. The claimant stated, “