MENTAL IMPAIRMENT QUESTIONNAIRE/Impact Disability Law

Patient:

First NameLast Name

Treating Source(s):

Please answer the following questions concerning your patient’s impairments

1. Frequency and length of contact:

2. Diagnoses:

3a. List of prescribed medications:

3b. Describe any side effects of medications that may have implications for working. E.g., dizziness, drowsiness, fatigue, lethargy, stomach upset, etc.:

4. Describe the clinical findings including results of mental status examination that demonstrate the severity of your patient's mental impairment and symptoms:

5. Prognosis:

6. Has your patient’s impairment lasted or can it be expected to last at least twelve months?

YesNo

7. To determine your patient’s ability to do work-related activities on a day-to-day basis in a regular work setting, please give us your opinion based on your examination of how your patient’s mental/emotional capabilities are affected by the impairment(s). Consider the medical history, the chronicity of findings (or lack thereof), and the expected duration of any work-related limitations, but not your patient’s age, sex or work experience.

Seriously limited, but not precluded means ability to function in this area is less than satisfactory, but not precluded in all circumstances. Individual would be limited in their ability to perform activity 15% of time.
Unable to meet competitive standards means your patient cannot satisfactorily perform this activity independently, appropriately, effectively and on a sustained basis in a regular work setting.
No useful ability to function, an extreme limitation, means your patient cannot perform this activity in a regular work setting.

Sustained Concentration and Persistence Limitations:

	Unlimited or Very Good	Limited but satisfactory	Seriously limited, but not precluded	Unable to meet competitive standards	No useful ability to function
Carry out very short and simple instructions
Carry out detailed instructions
Maintain attention and concentration for extended periods
Perform activities within a schedule
Manage regular attendance and be punctual within customary tolerances
Sustain an ordinary routine without special supervision
Work in coordination with or in proximity to others without being distracted by them
Complete a normal workday and workweek without interruptions from psychologically based symptoms
Perform at a consistent pace without an unreasonable number and length of rest periods

Understanding and Memory Limitations:

	Unlimited or Very Good	Limited but satisfactory	Seriously limited, but not precluded	Unable to meet competitive standards	No useful ability to function
Remember locations and work-like procedures
Understand and remember very short and simple instructions
Understand and remember detailed instructions

Social Interaction Limitations:

	Unlimited or Very Good	Limited but satisfactory	Seriously limited, but not precluded	Unable to meet competitive standards	No useful ability to function
Interact appropriately with the general public
Ask simple questions or request assistance
Accept instructions and respond appropriately to criticism from supervisors
Get along with coworkers or peers without distracting them or exhibiting behavioral extremes
Maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness

Adaptation Limitations:

	Unlimited or Very Good	Limited but satisfactory	Seriously limited, but not precluded	Unable to meet competitive standards	No useful ability to function
Respond appropriately to changes in the work setting
Be aware of normal hazards and take appropriate precautions
Set realistic goals or make plans independently of others

8. On average, how often do you anticipate that your patient’s impairments or treatment would cause your patient to be absent from work? (E.g., days per week or days per month)

9. On average, how much of an 8-hour work day do you anticipate the symptoms of your patient’s impairments would cause your patient to be off task from performing job tasks?

E.g., percentage of day, minutes per hour, or minutes per day

Printed/Typed Name:

Signature

Date

Printed/Typed Name:

Signature

Date