HEADACHES MEDICAL SOURCE STATEMENT/Impact Disability Law

HEADACHES MEDICAL SOURCE STATEMENT
From:
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. Diagnoses:
3. Does your patient have headaches?

YesNo
a. What type of headache does your patient have?

MigraineVascular tensionClusterPost concussion syndromeOther
b. Please describe the intensity your patient’s headaches:

MildModerateSevere
4. Identify any other symptoms associated with your patient’s headaches:

VertigoWeight changeVisual disturbancesNausea/vomitingInability to concentrateMood changesMalaiseImpaired sleepMental confusionPhotophobiaExhaustionImpaired appetiteThrobbing painPhonophobiaWorse with activityOther
5. If there are premonitory symptoms or aura, please describe:
6. What is the approximate frequency of headaches? per week/ per month
7. What is the approximate duration of a typical headache? minutes/ hours
8. Identify any impairment(s) that could reasonably be expected to explain your patient’s headaches:

Anxiety/tensionIntracranial infection or tumorCerebral hypoxiaMigraineCervical disc diseaseSeizure disorderHistory of head injurySinusitusHypertensionSubstance abuseOther
9. What triggers your patient’s headaches?

AlcoholLack of sleepBright lightsMenstruationHungerNoiseStressStrong odorsVigorous exerciseWeather changes Food - identify:
Other:
10. What makes your patient’s headaches worse?

Bright lightsMoving aroundCoughing, straining/bowel movementNoiseOther
11. What makes your patient’s headaches better?

Lie downQuiet placeHot packTake medicationDark roomCold packOther
12. To what degree do emotional factors contribute to the severity of your patient’s headaches?

Not at allSomewhatVery much
Please explain:
13. To what degree can your patient tolerate work stress?

Incapable of even "low stress" workCapable of low stress workCapable of moderate stress - normal workCapable of high stress work
Please explain the reasons for your conclusion:
14. Describe the treatment and response:
15. Identify side effects of medications experienced by your patient:
16. Prognosis:
17. Have your patient’s impairments lasted or can they be expected to last at least twelve months?

YesNo
18. During times your patient has a headache, would your patient generally be precluded from performing even basic work activities and need a break from the workplace?

YesNo
Please explain
19. Will your patient sometimes need to take unscheduled breaks during a working day?

YesNo
1. how often do you think this will happen?
2. how long (on average) will your patient have to rest before returning to work?
3. on such a break, will your patient need to ̈ lie down or ̈ sit quietly?
20. Not counting breaks, how much is your patient likely to be “off task” while at work? 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
21. 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
22. Are your patient’s impairments (physical impairments plus any emotional impairments) reasonably consistent with the symptoms and functional limitations described in this evaluation?

YesNo
Please explain:
23. Please describe any other limitations (such as limitations in the ability to sit, stand, walk, lift, bend, stoop, crouch, 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 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.

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