Attending Physician'S Statement Additional Report - Psychological Illness
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2Attending Physician's Statement Additional Report
Psychological Illness
For physical illness, complete the other side of this form.
IDENTIFICATION
(the insured must complete this section)
Last Name: _____________________________________ First Name: ___________________________________ Date of Birth: ______________________
Policy No: ____________________________________________________ Public Health Insurance No: ________________________________________
(complete in block letters and give to the patient)
ATTENDING PHYSICIAN’S STATEMENT
1. DIAGNOSIS
1.1. Primary: ________________________________________________________________
Code CIM-9: ___________________________________
1.2. Secondary: ______________________________________________________________ Code CIM-9: ___________________________________
1.3. Please describe the signs and symptoms and indicate the frequency and their individual degree of severity (M=mild, Md=moderate, S=severe)
Signs
M
Md
S
Symptoms
M
Md
S
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
2.TREATMENT
2.1. Medication – name and dosage: ____________________________________________________________________________________________
2.2. Is the patient consulting a:
Provide dates
Is the patient treated:
Specify
psychiatrist
❑ yes ❑ no _____________________________ in a treatment centre
❑ yes ❑ no _______________________________
psychologist
❑ yes ❑ no _____________________________ in a medical clinic
❑ yes ❑ no _______________________________
social worker
❑ yes ❑ no _____________________________ in a day hospital
❑ yes ❑ no _______________________________
other caregiver
❑ yes ❑ no _____________________________ in group therapy
❑ yes ❑ no _______________________________
in individual therapy
❑ yes ❑ no _______________________________
AXIS II) Associated personality disorders?
❑ yes ❑ no Specify: __________________________________________
Associated drug addiction, alcoholism or gambling problems?
❑ yes ❑ no Specify: __________________________________________
AXE III) MalaAXIS III) Associated illness: — diagnosis:
— drugs prescribed: ___________________________________________________________________________
AXIS IV) Associated psychological stress factors (in the last 12 months):
❑ marital/family life
❑ loss of employment or layoff
❑ professional problems
❑ personal or interpersonal problems
❑ alcohol or drug abuse and/or gambling problems
❑ other problems, specify:________________________________________________________________________________________________
AXIS V) General scale of functioning (according to the GAF scale of the DSM IV (0 to 100) 100=perfect condition)
— at the beginning of treatment: ______________________________________ — currently: _________________________________________
3. FOLLOW-UP AND PROGNOSIS
3.1. Date of last consultation for this disability: _____________________________ Date of next consultation: __________________________________
3.2. Frequency of follow-up: ___________________________________________________________________________________________________
3.3. Has the patient been, or will be, referred to a psychiatrist?
❑ yes ❑ no
Name of physician: _______________________________________
3.4. Patient’s cooperation in the treatment:
❑ excellent
❑ average
❑ poor
3.5. If you anticipate that the absence from work will exceed the usual period for such a diagnosis, please specify the factors justifying your prognosis.
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
3.6. Would your patient benefit from assistance within the scope of a return to work? ❑ yes ❑ no
3.7. Do you consider that the patient’s condition has improved in an optimal way? ❑ yes ❑ no
3.8. Approximate duration of disability: ____days _______ weeks
❑ To be determined or date of return to work: _____________________________
3.9. When will this patient be able to return to work? _______ days _______ weeks
❑ part-time
❑ full-time
❑ gradual return
Please specify: ____________________________________________________________________
- Please add any comments that would help us better understand your patient’s medical condition.
4. COMMENTS
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
STATEMENT
First and Last name: ______________________________________________________________ Telephone: _________________________________
Address: _______________________________________________________________________ Fax: _______________________________________
❑ General practitioner ❑ Specialist Please specify: ____________________________________ Licence No: _________________________________
Signature: ______________________________________________________________________ Date: ______________________________________
day /month/ year
Note: The claimant must pay any fees requested to complete this form.
01QRI0054A (02-13)
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