Re: Appointment with lawyer

[Guest guest]

Hi Teri,

The " form " isn't on-line, I only have an old one in my home files,

but I'll describe it. It is quite simple, but 4 pages in 2 parts.

1Short answer questions.

Top of it says " Neurological " in big letters. Has the client's name,

case number and the doctor's DEA number.

Questions on the form:

1. Please attach medical records including lab reports for specified

dates.

2. What is the patient's diagnosis?

3. Date of onset of symptoms?

4. Prognosis

5. Is there a disturbance of speech?

6. Is expressive or receptive aphasia present?

7. Are there any reflex abnormalities?

8. Please indicate extremities affected by tremor and/or weakness

and grade severity. Please use these motor ratings to describe your

patient 0/0; 1/5; 2/5; 3/5; 4/5; 5/5

9. Is there any loss of use of extremities? Please describe

extremity involved and comment on severity.

10. If there is any loss of the patient's ability to use his hands

for fingering or handling, please describe.

11. If constractures are present please describe.

12. If there is disturbance of gait please describe.

13. Is an assistive device needed for ambulation? If so is it used

for long distance, short distance. How long can the patient walk

without assistive device? Is an assistive device needed for balance?

Is an assistive device needed to walk on even or uneven terrain?

14. If atropy is present, please describe.

15. If sensory and/or motor abnormalities are present, please

describe.

16. Have there been any seizures in the past 12 months?

17. If present, please give type and degree of ocular involvement.

18. If present, please comment on any loss of cognitive ability,

personality change, abnormal behavior.

19. If a severe impairment is present, is this patient capable of

managing benefits in his/her own behalf?

20. Additional comments.

(Then a place for Doctor to sign, date and give phone number with

best time to call)

PART 2 MEDICAL SOURCE STATEMENT-PHYSICAL

1. Are lifting/carrying affected by the impairments?

2. What is the patient's' maximum capacity to lift and/or carry.

What medical findings support your assessment?

3. What is the patient's ability to stand and or walk with normal

breaks? What medical findings support your assessment?

4. Does the patient use an assistive device? What medical findings

support your assessment? Who prescribed it? Is it medically

necessary?

5. What is the patient's ability to sit with normal breaks? What

medical findings support your assessment?

6. Does the patient need alternate standing and sitting? How often

does the patient require a change in position? What medical findings

support your assessment?

7. Which of the following can the patient do/not do, either limited,

frequently, occassionally, never, or unlimited?

Climbing, balancing, stooping,kneeling, crouching, crawling,

reaching, handling, fingering, feeling. If there are any

restrictions, please give the degree of limitation and supportive

evidence.

8. Are there any environmental restrictions caused by the patient's

impairments? Heights, moving machinery, temperature extremes,

chemicals, dust, other. What medical findings support your

assessment?

9. What was the last date you saw this patient?

10.What is the prognosis?

And another place for the doctor to sign, date and add phone number.

OK there you go Teri. If your Internist is the one who best knows

your CMT, he/she's the one to complete the form. Better yet that you

have a neurologist that you see regularly do this.

If this above information cannot be given by your docs, then the SSA

may wish to send you to one of their docs - in which case I

recommend you ask for a neurologist that understands CMT. Going to

one of the SSA docs is also known as a " consultative examination " .

If you receive a notice of this, you must go, failure to do so

negatively affects your case.

~ Gretchen