The following is an example of a health questionnaire that an attorney would send to a treating physician. The purpose is to gather medical information for presentation to the Social Security Administration (SSA) to support a claim for disability.
Many attorneys request a written assessment from the treating physician. If the doctor isn’t familiar with the SSA requirements (listed in SSA’s “Blue Book”), the attorney would provide a written guidelines to the physician to ensure the required information is included in the written assessment. This questionnaire would serve as that guide.
This form would be useful to a person who chooses to forego an attorney. One note of caution: doctors usually charge for providing this information/service, a charge that could exceed $300.
Please answer the following questions concerning your patient’s impairments. Attach all relevant treatment notes, laboratory and test results that have not been provided previously to the Social Security Administration.
1. Nature, frequency and length of contact:
3. Identify the clinical findings and test results that support your diagnoses (e.g., multiple sleep latency test, REM testing, EEG, polysomnographic studies, etc.):
4. Identify all of your patient’s symptoms, including (check all that apply):
– Cataplectic attacks
– Sleep paralysis
– Excessive daytime sleepiness
– Hypnagogic phenomena
– Sleep attacks
– Sleep apnea
– Personality change
– Chronic pulmonary
– Disturbance in cognitive function
– Memory impairment
– Automatic behavior
5. For the above symptoms, estimate frequency and duration of each symptom:
6. Does your patient normally have signs just prior to a spell? Yes No
If yes, please describe typical signs:
7. Do certain situations (e.g., exertion, stress, fatigue excitement) tend to trigger these spells? Yes No
8. Is your patient a malingerer? Yes No
9. Does abuse of alcohol or drugs cause or contribute to your patient’s symptoms and functional limitations? Yes No
10. Do emotional factors contribute to the severity of your patient’s symptoms and functional limitations? Yes No
11. Are your patient’s impairments (physical impairments plus any emotional impairments) reasonably consistent with the symptoms and limitations described in this evaluation? Yes No
12. Treatment and response, including list of medications prescribed and their side effects on our patient (e.g., drowsiness, ataxia, nystagmus, etc.):
13. Is your patient presently taking medications as prescribed? Yes No
15. Have your patient’s impairments lasted or can they be expected to last at least 12 months? Yes No
16. Please check appropriate boxes below which describe the limitations from your patient’s impairments:
– Should avoid work involving climbing and heights.
– Should avoid power machines, moving machinery or other hazardous conditions.
– Should limit or avoid operation of motor vehicles.
– Should avoid work, which is not closely supervised where a spell could occur in isolation.
– Supervisors and/or co-workers must be trained for basic assistance.
– May need breaks at unpredictable intervals during workday due to spells, adverse effects of medications, etc.
Describe anticipated frequency and duration of breaks:
– Maximum lift/carry _______ pounds on an occasional basis.
– Should avoid work that involves mainly standing and walking (as opposed to sitting) throughout the workday.
Non-exertion limitations: indicate areas where your patient has serious limitations in performing the following activities in the workplace on a sustained basis:
– Understanding, remember and carry out simple instructions
– Maintain attention for two hour segments
– Be punctual within customary, usually strict tolerances
– Sustain an ordinary routine without special supervision
– Perform at a consistent pace
– Deal with normal work stresses
– Maintain socially appropriate behavior
– Travel in unfamiliar places
– Use public transportation
17. Are your patient’s impairments likely to produce “good days” and “bad days”? Yes No
If yes, please estimate on the average, how often your patient is likely to be absent from work as a result of the impairments or treatment:
– Less than once a month
– About once a month
– About twice a month
– About three times a month
– About four times a month
– More than four times a month
18. Please describe any other limitations (such as limitations in the ability to sit, stand, walk, lift, bend, stoop, limitations in using arms, hands, fingers, limited vision, difficulty hearing, need to avoid temperature extremes, wetness, humidity, noise, dust, fumes, gases or hazards, etc.) that would effect your patient’s ability to work at a regular job on a sustained basis: