1. MENTAL DISORDERS REPORT BY PSYCHIATRIST/PSYCHOLOGIST
(TREATING MEDICAL SOURCE’S ASSESSMENT/OPINION)
Doctor: ______________________________
Patient: ______________________________ Patient’s SSN: ____________________
Please answer the following questions (check-marking sections as necessary) concerning your patient’s impairments – these
questions are designed to discover both the symptoms from the diagnosis, and the impact of those symptoms on the ability of
your patient to function in a work setting. This report consists of a two-page narrative with attachment(s). Please sign and
initial each page of the report where indicated.
1. When did you begin treating the patient? __________________________________________________________
2. Have your patient’s impairments ___ lasted, or can they be ___ expected to last, at least 12 months? ___ Yes ___ No
3. Diagnosis: _________________________________________________________________________________
4. Please describe your treatment, including the frequency and type of therapy, as well as the name, strength, and
frequency of past and present medication(s) prescribed:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. When did you last examine/assess the patient? ________________________________________________________
6. Are there certain situations that cause or trigger the patient’s symptoms? If so, please describe them briefly:
____________________________________________ Encounters with other people
____________________________________________ Encounters with groups of people
_____________________________________________ Coping with supervisors, co-workers, public
_____________________________________________ Stress (e.g., having time or productivity demands)
_____________________________________________ Dealing with family
_____________________________________________ Travel or leaving the home environment
7. Does this illness markedly restrict daily activities? ___ Yes ___ No
Please explain:
________________________________________________________________________________________
8. Has this illness has impacted on the patient’s ability to sustain concentration and attention resulting in a frequent failure to
complete tasks? ___ Yes ___ No
Please explain:
__________________________________________________________________________________________
Initials __________

2. 9. Is this patient living in a highly supportive and protective setting which is helping to attenuate some of the more severe
symptoms? ___ Yes ___ No
If yes, please explain how this patient would function outside of this setting:
__________________________________________________________________________________________
10. In your treating medical opinion, to a reasonable medical certainty, is your patient able to function in a competitive work
setting (not a sheltered work shop position, but in a setting with time and productivity demands) on an eight hours per
day, five days per week basis? ___ Yes ___ No
11. If the answer to number 10 above is “No” is this due to the signs, symptoms, limitations and impairments as herein
noted/described? ___ Yes ___ No
12. Date on or about which the disability began as noted in number 10 above: ________________________________
13. Does the patient suffer side effects from prescribed medications (___ drowsiness, ___ stomach upset, ___ dry
eyes/mouth, etc.)?
__________________________________________________________________________________________
14. GAF scale assessment: _____ Current _____ Highest level in past year
15. What has been the patient’s response to treatment and what is your prognosis?
__________________________________________________________________________________________
16. If the patient has a record of infrequent or irregular medical visits or failure to seek medical treatment, is there a good
reason (___ patient is living with symptoms and seeing doctor only as needed for periodic evaluation and renewal of
medications, ___ patient takes no medication as side effects are less tolerable than symptoms, ___ patient is unable to
afford treatment, ___ doctor has advised patient that there is no further, effective treatment that would benefit patient,
___ treatment may be contrary to the patient’s religion, etc.) for this (please explain)?
__________________________________________________________________________________________
17. Based upon your examinations, subjective and objective findings, to a reasonable medical certainty, are your patient’s
complaints and descriptions of symptoms credible? ___ Yes ___ No
18. Is your patient a malingerer? ___ Yes ___ No
19. Are there other medical or psychological conditions which significantly limit/impair your patient’s ability to function in
addition to those you already listed (please explain)?
____________________________________________________________________________________________
____________________________________________________________________________________________
20. Other comments:
____________________________________________________________________________________________
____________________________________________________________________________________________
Signature: ________________________________________ Date: __________________________
Printed Name: ________________________________________ Phone: __________________________
Address: __________________________________________________________________________

3. In addition to the above information, the Social Security Administration’s regulations contain specific “Listings” of
impairments that are used to identify serious claims that should be awarded more expeditiously. Please review each of the
following sections and answer those portions relating to your diagnoses. Each section has two parts: a description of the
Symptoms, and then questions relating to the Functional Limitations. Please make certain that you indicate your
opinions for each part of your diagnoses.
If the diagnosis is an Affective Disorder (12.04) (Depression, Bi-Polar Disorder, Dysthymia, Adjustment Disorder),
please identify which disorder and the following signs and symptoms you have noticed during your treatment:
A. ____ Depressive syndrome manifested by at least four of the following symptoms---circle the symptoms as
appropriate:
a. Anhedonia b. Appetite disturbance
c. Sleep disturbance d. Psychomotor agitation or retardation
e. Decreased energy f. Feelings of guilt or worthlessness
g. Difficulty concentrating/thinking h. Thoughts of suicide
i. Hallucinations, delusions or paranoid thinking
B. ____ Manic syndrome (manifested by at least three of the following symptoms, either continuous or
intermittent---circle the symptoms as appropriate):
a. Hyperactivity b. Pressure of speech c. Flight of ideas
d. Inflated self-esteem e. Decreased need for sleep f. Easy distractibility
g. Hallucinations, delusions or paranoid thinking
h. Involvement in activities with high probability of painful consequences that are not recognized
C. ____ Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both
manic and depressive syndromes (and currently characterized by either or both syndromes).
Functional limitations related to Affective Disorder
Rank the limitations in the following areas of function:
Mild Moderate Marked Severe Extreme
1. Restriction of activities of daily living ___ ___ ___ ___ ___
2. Difficulties in maintaining social functioning ___ ___ ___ ___ ___
3. Difficulties in maintaining concentration, persistence or pace ___ ___ ___ ___ ___
4. Repeated episodes of decompensation of extended duration ___ ___ ___ ___ ___
OR, ____ is there a medically documented history of a chronic affective disorder of at least 2 years’ duration that has caused
more than a minimal limitation of ability to do basic work activities, with symptoms or signed currently attenuated by
medication or psychosocial support, and at least one of the following:
1. Repeated episodes of decompensation, each of extended duration ______
2. A residual disease process resulting in marginal adjustment that even a small increase in mental demands or change
in environment would be predicted to cause decompensation ______
3. Current history of 1 or more years’ inability to function outside of a highly supportive living arrangement, with an
indication of continued need for such an arrangement ______
Signature: _______________________________________________________________
Printed Name: _______________________________________________________________
Date: ______________________________

4. If the diagnosis is an Anxiety-Related Disorder (12.06) (anxiety is either the predominant disturbance, or it is
experienced if the patient attempts to master symptoms; for example, confronting the dreaded object or situation in a
phobic disorder or resisting the obsessions or compulsions in obsessive compulsive disorders) identify which of the
following signs and symptoms you have noticed during your treatment:
A. Medically documented findings of at least one of the following---check mark and circle the symptoms as
appropriate:
1. ____Generalized persistent anxiety accompanied by three of the following:
a. Motor tension b. Automatic hyperactivity
c. Apprehensive expectation d. Vigilance and scanning
OR,
2. ____ A persistent irrational fear of a specific object, activity, or situation that results in a compelling
desire to avoid the dreaded object, activity, or situation.
OR,
3. ____ Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense
apprehension, fear, terror and sense of impending doom occurring on average at least once a week.
OR,
4. ____ Recurrent obsessions or compulsions which are a source of marked distress.
OR,
5. ____ Recurrent and intrusive recollections of a traumatic experience, which are a source of marked
distress.
Functional limitations related to Anxiety-Related Disorder
Rank the limitations in the following areas of function:
Mild Moderate Marked Severe Extreme
1. Restriction of activities of daily living ___ ___ ___ ___ ___
2. Difficulties in maintaining social functioning ___ ___ ___ ___ ___
3. Difficulties in maintaining concentration, persistence or pace ___ ___ ___ ___ ___
4. Repeated episodes of decompensation of extended duration ___ ___ ___ ___ ___
OR, ____ is there a complete inability to function outside the area of the patient’s home? ________
Signature: _______________________________________________________________
Printed Name: _______________________________________________________________
Date: ______________________________

5. If the diagnosis is an Personality Disorder (12.08) (inflexible and maladaptive personality traits causing significant
impairment in social or occupational functioning or subjective distress – characteristic features are typical of the patient’s long-
term functioning and are not limited to discrete episodes of illness) please identify whether you, during your treatment, found
deeply ingrained, maladaptive patterns of behavior associated with at least one of the following:
____ Seclusiveness or autistic thinking ____ Pathologically inappropriate suspiciousness or hostility
____ Oddities of thought, perception, speech and behavior ____ Persistent disturbances of mood/affect
____ Pathological dependence, passivity or aggressivity
____ Intense and unstable interpersonal relationships and impulsive and damaging behavior
Functional limitations related to Personality Disorder
Rank the limitations in the following areas of function:
Mild Moderate Marked Severe Extreme
1. Restriction of activities of daily living ___ ___ ___ ___ ___
2. Difficulties in maintaining social functioning ___ ___ ___ ___ ___
3. Difficulties in maintaining concentration, persistence or pace ___ ___ ___ ___ ___
4. Repeated episodes of decompensation of extended duration ___ ___ ___ ___ ___
Signature: _______________________________________________________________
Printed Name: _______________________________________________________________
Date: ______________________________

6. If the diagnosis is a Schizophrenic, Paranoid or other Psychotic Disorder (12.03) (characterized by the onset of psychotic
features with deterioration from a previous level of functions) please identify whether you, during your treatment, found
deeply ingrained, maladaptive patterns of behavior associated at least one of the following:
A. Medically documented persistence, either continuous or intermittent, of one or more of the following---check mark
and circle as appropriate:
1. ____ Delusions or hallucinations
2. ____ Catatonic or other grossly disorganized behavior
3. ____ Incoherence, loosening of associations, illogical thinking or poverty of content of speech with one
of the following: a. Blunt affect b. Flat affect c. Inappropriate affect
4. ____ Emotional withdrawal and/or isolation
Functional limitations related to Schizophrenic, Paranoid or Psychotic Disorders
Rank the limitations in the following areas of function:
Mild Moderate Marked Severe Extreme
1. Restriction of activities of daily living ___ ___ ___ ___ ___
2. Difficulties in maintaining social functioning ___ ___ ___ ___ ___
3. Difficulties in maintaining concentration, persistence or pace ___ ___ ___ ___ ___
4. Repeated episodes of decompensation of extended duration ___ ___ ___ ___ ___
OR, is there a medically documented history of chronic schizophrenic, paranoid, or other psychotic disorder of at
least 2 years’ duration that has caused more than a minimal limitation of ability to do basic work activities, with
symptoms or signs attenuated by medication or psychosocial support, along with one of the following:
____ Repeated episodes of decompensation, each of extended duration
____ A residual disease process that has resulted in such marginal adjustment that even a minimal increase in
mental demands, or changes in environment, would be predicted to cause decompensation; or
____ A current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an
indication of continued need for such an arrangement
Signature: _______________________________________________________________
Printed Name: _______________________________________________________________
Date: ______________________________

7. If the diagnosis is Mental Retardation(12.05) (significantly subaverage general intellectual functioning with deficits initially
manifested during the developmental period; i.e., the evidence demonstrates or supports onset of the impairment before age
22) identify which of the following signs you have noticed during your treatment:
A. ____ Mental incapacity evidenced by dependence upon others for personal needs (e.g. toileting, eating, dressing, or
bathing) and inability to follow directions, such that the use of standardized measures of intellectual functioning is
precluded;
OR,
B. ____ A valid verbal, performance, or full scale IQ of 59 or less
OR,
C. ____ A valid, verbal, performance, or full scale IQ of 60 through 70 resulting in at least two of the following:
Rank the limitations in the following areas of function:
Mild Moderate Marked Severe Extreme
1. Restriction of activities of daily living ___ ___ ___ ___ ___
2. Difficulties in maintaining social functioning ___ ___ ___ ___ ___
3. Difficulties in maintaining concentration, persistence or pace ___ ___ ___ ___ ___
4. Repeated episodes of decompensation of extended duration ___ ___ ___ ___ ___
Signature: _______________________________________________________________
Printed Name: _______________________________________________________________
Date: ______________________________

8. If the diagnosis is Organic Mental Disorder (12.02) (psychological or behavioral abnormalities associated with a dysfunction
of the brain; history and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged
to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities) please, identify
which of the following signs you have noticed during your treatment:
A. ____ Demonstration of a loss of specific cognitive abilities or affective changes and the medically documented
persistence of at least one of the following---check mark as appropriate:
1. ____ disorientation to time and place
2. ____ memory impairment either short term (inability to learn new information), intermediate, or long-
term (inability to recall information known in the past)
3. ____ perceptual or thinking disturbances (e.g. hallucinations, delusions)
4. ____ change in personality
5. ____ disturbance in mood
6. ____ emotional lability (e.g. explosive temper outbursts, sudden crying, etc.) and impairment in impulse
control
7. ____ loss of measured intellectual ability of at least 15 I.Q. points from premorbid levels or overall
impairment index clearly within the severely impaired range on neuropsychological testing, e.g. the
Luria-Nebraska, Halstead-Reitan, etc.
Functional limitations related to Organic Mental Disorders
Rank the limitations in the following areas of function:
Mild Moderate Marked Severe Extreme
1. Restriction of activities of daily living ___ ___ ___ ___ ___
2. Difficulties in maintaining social functioning ___ ___ ___ ___ ___
3. Difficulties in maintaining concentration, persistence or pace ___ ___ ___ ___ ___
4. Repeated episodes of decompensation of extended duration ___ ___ ___ ___ ___
OR,
is there a medically documented history of chronic organic mental disorder of at least 2 years’ duration that has caused
more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by
medication or psychosocial support, along with the following:
____ repeated episodes of decompensation, each of extended duration
Signature: _______________________________________________________________
Printed Name: _______________________________________________________________
Date: ______________________________