*
1. Patient's Name
First Name
Last Name
2. Date of Birth
*
MM
DD
YYYY
3. Gender
*
4. Marital Status
*
5. Current Age
*
6. Email
*
7-9. Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
10. Phone
*
(###)
###
####
Employer
11. Employer Name
*
12-15. Employer Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
16. Employer Contact Information (if applicable)
First Name
Last Name
17. Employer Phone
*
(###)
###
####
19-22.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
23. Disability Insurance Contact Name
*
24. Disability Contact Phone Number
(###)
###
####
25. Disability Insurance Company Phone Number
(###)
###
####
26. Disability Insurance Company Fax Number
(###)
###
####
DESCRIPTION OF THE NATURE OF THE DISABILITY
27. Please explain the reason that you are seeking/continuing disability/medical leave at this time: (what symptoms are you experiencing and how do these symptoms prevent you from being able to do your job)
*
28. In the space below, please provide a description of the type of work you do:
*
29. What have you tried to do to address these symptoms so far?
*
30. Approximately when did this current episode begin or start to worsen?
*
31. When was your first missed day of work?
*
MM
DD
YYYY
32. What is the start date of your disability leave?
*
MM
DD
YYYY
33. If known, what date is the projected end of your disability leave?
*
MM
DD
YYYY
34. Please list the days of work which you have missed or have worked less than a full day as a result of the current issue since the last time you submitted a report.
35. If applicable, please list the name(s) of all the physician(s) or other clinicians who you are seeing including their address, phone, and fax numbers. (one line per clinician)
Physician 1
First Name
Last Name
Physician 1 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician 1 Phone
(###)
###
####
Physician 2
First Name
Last Name
Physician 2 Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Physician 2 Phone
(###)
###
####
36. Do you think that you would be able to perform your job duties in an alternative work setting? Yes No
37. Disability or medical leave is typically intended to provide the opportunity to pursue more aggressive forms of treatment. It is usually the expectation of an employer that the patient be involved in active, routine care on an ongoing basis. If granted this leave, how will you use your time to prepare to return to work? (check all that apply)
38. What type of leave are you requesting? (check all that apply)
39. For an INTERMITTENT leave of absence, please list the number of days per month that you think that you may require to be off work or the number of hours per week.
40. SYMPTOM CHECKLIST
*
PHQ-9 DEPRESSION RATING SCALE:
PHQ-9 DEPRESSION RATING SCALE: Over the last 2 weeks (14 days), How often have you been bothered by any of the following problems?*
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
41. Little interest or pleasure in doing things
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
42. Feeling down, depressed, or hopeless
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
43. Trouble falling asleep or staying asleep, or sleeping too much
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
44. Feeling tired or having little energy 1
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
45. Poor appetite or overeating
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
46. Feeling bad about yourself or that you are a failure or have let yourself or your family down
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
47. Trouble concentrating on things such as reading the newspaper or watching television
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
48. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
49. Thoughts that you would be better off dead, or of hurting yourself in some way
*
1. Not at all
2. Several days
3. More than half of the days
4. Almost all days
50. Please list each medication, vitamin, supplement you are currently taking including the name, strength, number, and how often you take it during the day. Please list one medication per line Enter your answer
51. Concentrating on doing something for 10 minutes?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
52. Remembering to do important things?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
53. Analyzing and finding solutions to problems in day-to-day life?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
54. Learning a new task, for example, learning how to get to a new place?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
55. Generally understanding what people say?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
56. Starting and maintaining a conversation?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
57. Standing for long periods such as 30 minutes?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
58. Standing up from sitting down?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
59. Moving around inside your home?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
60. Getting out of your home?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
61. Walking a long distance such as a kilometer [or equivalent]?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
62. Washing your whole body?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
63. Getting dressed?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
64. Eating?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
65. Staying by yourself for a few days?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
66. Dealing with people you do not know?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
67. Maintaining a friendship?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
68. Getting along with people who are close to you?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
69. Making new friends?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
70. Sexual activities?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
71. Taking care of your household tasks well?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
72. Doing most important household tasks well?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
73. Getting all the household work done that you needed to do?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
74. Getting your household work done as quickly as needed?
*
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extreme/Can't Do
