DYSAUTONOMIA MEDICAL SOURCE STATEMENT/Impact Disability Law

DYSAUTONOMIA MEDICAL SOURCE STATEMENT
From:
Doctor/Practice Name
Re:
Name of Patient
Please answer the following questions concerning your patient’s impairments. Attach relevant treatment notes, radiologist reports, laboratory and test results as appropriate.
1. Frequency and length of contact:
2. Diagnosis:

Postural Orthostatic Tachycardia Syndrome (POTS)Multiple System Atrophy (MSA)Neurocardiogenic Syncope (NCS)Other
3. Which of the following symptoms are present in your patient:

DiarrheaNausea and vomiting, abdominal painDizziness/LightheadednessSyncopeWeakness Overwhelming exhaustion/fatigueBrain fog / neurocognitive dysfunctionExercise intoleranceChest pain HeadachesBone pain Insomnia and frequent awakenings from sleepAngioedema (swelling)Shakiness or tremorsTemperature deregulationLow blood pressure/blood pressure instabilityRapid heart rate (tachycardia)Blurred visionOther
4. As a result of your patient’s impairments, estimate your patient’s functional limitations if your patient were placed in a competitive work situation.

a. Please indicate how long your patient can sit and stand/walk total in an 8-hour working day (with normal breaks):
Sit:

less than 2 hoursabout 2 hoursabout 4 hoursat least 6 hours
Stand/walk:

less than 2 hoursabout 2 hoursabout 4 hoursat least 6 hours
b. Does your patient need a job that permits shifting positions at will from sitting, standing or walking?

YesNo
c. With prolonged sitting, should your patient’s leg(s) be elevated?

YesNo
How high should the leg(s) be elevated?
If your patient had a sedentary job, what percentage of time during an 8-hour working day should the leg(s) be elevated?
What symptoms cause a need to elevate the leg(s)?
d. Will your patient sometimes need to take unscheduled breaks during a working day?

YesNo
How often do you think this will happen?
How long (on average) will your patient have to rest before returning to work?
What symptoms cause a need for breaks?
e. How much is your patient likely to be “off task”? That is, what percentage of a typical workday would your patient’s symptoms likely be severe enough to interfere with attention and concentration needed to perform even simple work tasks?

0%5%10%15%20%25% or more
f. Are your patient’s impairments likely to produce “good days” and “bad days”?

YesNo
Assuming your patient was trying to work full time, please estimate, on the average, how many days per month your patient is likely to be absent from work as a result of the impairments or treatment:

NeverAbout three days per monthAbout one day per monthAbout four days per monthAbout two days per monthMore than four days per month
5. Please describe any other limitations (such as psychological limitations, limited vision, difficulty hearing, need to avoid temperature extremes, wetness, humidity, noise, dust, fumes, gases or hazards, etc.) that would affect your patient’s ability to work at a regular job on a sustained basis:
Attach all relevant treatment notes, laboratory and test results, which have not been provided previously to the Social Security Administration.

You can upload multiple files at a time.
Cancelof
Date

MonthDayYear
Date
Signature
Printed/Typed Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: