MAST CELL DISEASE MEDICAL SOURCE STATEMENT/Impact Disability Law

MAST CELL DISEASE 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:

Mastocytosis (all variants/types)Mast Cell Activation Syndrome (MCAS)Hereditary alpha Tryptasemia (HaT)
3. Which of the following symptoms are present in your patient:

DiarrheaNausea and vomiting, abdominal painLightheadednessSyncopeWeaknessOverwhelming exhaustion/fatigueBrain fog / neurocognitive dysfunctionItching, +/- rash, hivesChest painHeadachesBone painAnaphylaxisAngioedema (swelling)Wheezing/shortness of breathThroat swellingLow blood pressure/blood pressure instabilityRapid heart rate (tachycardia)
4. If your patient has pain, characterize the nature, location, frequency, triggers, and severity of your patient’s pain:
5. Identify the clinical findings and testing performed:
6. Describe the treatment and response including any side effects of medication that may have implications for working, e.g., drowsiness, dizziness, nausea, etc:
7. 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. 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. What symptoms cause a need for breaks?
b. 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
c. 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
8. 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.

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