part i: patient authorization part ii: attending …...part ii–vi to be completed by physician. 2....
TRANSCRIPT
Instructions 1. Please print. 3. Part II–VI to be completed by physician. 2. Part I to be completed by patient. 4. Any fee for completing this form is the patient’s responsibility.
PART I: PATIENT AUTHORIZATION Name _____________________________________________________________________________ Date of Birth I I Last First Initial YYYY MM DD I hereby authorize the release of any information herein requested by my insurer or its agent. Signature ___________________________________________________________________________ Date ____________________________
PART II: ATTENDING PHYSICIAN Name _________________________________________________________________ Specialty ______________________________________
Address ______________________________________________________________________________________________________________
Telephone ____________________________ Fax ______________________________ Email ________________________________________
Part III: HISTORY OF PRESENT CONDITION(S) 1. Diagnosis (using DSM IV criteria) Supporting Data
Axis I ___________________________________________________ Describe the symptoms (severity and frequency) and
__________________________________________________ medical or psychological test results that support each
Axis II ___________________________________________________ diagnosis.
___________________________________________________ _____________________________________________________
Axis III ___________________________________________________ _____________________________________________________
___________________________________________________ _____________________________________________________
Axis IV 0 1 2 3 4 5 6 _____________________________________________________
Axis V Current GAF (Global Assessment of Functioning (Score) _____________________________________________________
Highest GAF Score in past year _____________________________________________________
Lowest GAF Score in past year _____________________________________________________
2. Date symptoms first appeared ____ I_ _ I ___ YYYY MM DD
3. Initial examination date ____ I_ _ I ___ YYYY MM DD
4. Date patient ceased working due to this condition ____ I_ _ I ___ YYYY MM DD
5. Is condition due to injury or sickness arising from patient’s employment? Yes No Unknown
Have workers compensation forms been completed? Yes No Unknown
6. Symptoms (include severity & frequency)
____________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
7. Clinical findings (attach copies of clinical notes, medical and psychological test results, etc.)
___________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
8. Has the patient previously had a similar condition? Yes No If yes, specify date of initial onset _____ I_ _ _ I ____ YYYY MM DD
PART IV: FACTORS AFFECTING RECOVERY
Addiction __________________________________________________________________________________________________________
Social/family issues _________________________________________________________________________________________________
Workplace issues __________________________________________________________________________________________________
Coping skills ____ __________________________________________________________________________________________________
Family history of present condition _____________________________________________________________________________________
Physical/medical condition ___________________________________________________________________________________________
Personality/motivation _______________________________________________________________________________________________
Financial/legal problems _____________________________________________________________________________________________
Other issues _______________________________________________________________________________________________________
ATTENDING PHYSICIAN STATEMENT PSYCHIATRIC
PO Box 4030 Saskatoon SK S7K 3T2 306.244.1192 Toll-free in Saskatchewan 1.800.667.6853 Fax 306.652.5751 www.sk.bluecross.ca
9. Current height weight recent fluctuations
PART V: TREATMENT PLAN
1. Nature of therapy and goals ___________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Frequency of visits and length of therapy/counselling session _________________________________________________________________
__________________________________________________________________________________________________________________
3. Date of most recent visit _ I _ I________ YYYY MM DD
4. Hospitalization dates - include admission/discharge summaries
_________________________________________________________________________________ _ I _ I________
_________________________________________________________________________________ _ I _ I________
_________________________________________________________________________________ _ I _ I________
_________________________________________________________________________________ _ I _ I________
5. Medication
Name
Date started (YY|MM|DD)
Initial dosage
Initial response
Date of last dosage change (YY|MM|DD)
Current dosage
Response
Side-effects
Serum levels
Compliance
Date medication discontinued (YY|MM|DD)
6. Future treatment plans – what changes in treatment are being implemented or considered? __________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
7. Additional diagnostic testing? __________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
8. Name of other health care providers Specialty YYYY MM DD
Counsellor _____________________________________ __________________________________ I I______
Therapist _____________________________________ __________________________________ I I______
Other ________________________________________ __________________________________ I I______
9. Is the patient following recommended treatment program? Yes No
PART VI: ESTIMATED TIME FOR RECOVERY 1. Patient Progress
None Regressed Minimal Improvement Significant Improvement Plateaued Resolved
2. Patient Prognosis Poor Good
3. Which of your patient’s occupational duties are currently being affected by his/her condition? _______________________________________
_________________________________________________________________________________________________________________
4. In your opinion, is the patient a suitable candidate for rehabilitation? Yes No If no, explain.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
5. If unable to determine, follow up in ________________ weeks or _____________ months.
6. What is being done (or is needed) in the following areas to help your patient return to a productive lifestyle? (Tick all appropriate boxes)
Physical conditioning Stress management/coping skills
Social confidence-building Vocational counseling Other _________________________________________________________
7. Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Signature _____________________________________________________________ Date ___________________________________________
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee. MSI 382 09/13
PART V: TREATMENT PLAN
1. Nature of therapy and goals ___________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Frequency of visits and length of therapy/counselling session _________________________________________________________________
__________________________________________________________________________________________________________________
3. Date of most recent visit _ I _ I________ YYYY MM DD
4. Hospitalization dates - include admission/discharge summaries
_________________________________________________________________________________ _ I _ I________
_________________________________________________________________________________ _ I _ I________
_________________________________________________________________________________ _ I _ I________
_________________________________________________________________________________ _ I _ I________
5. Medication
Name
Date started (YY|MM|DD)
Initial dosage
Initial response
Date of last dosage change (YY|MM|DD)
Current dosage
Response
Side-effects
Serum levels
Compliance
Date medication discontinued (YY|MM|DD)
6. Future treatment plans – what changes in treatment are being implemented or considered? __________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
7. Additional diagnostic testing? __________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
8. Name of other health care providers Specialty YYYY MM DD
Counsellor _____________________________________ __________________________________ I I______
Therapist _____________________________________ __________________________________ I I______
Other ________________________________________ __________________________________ I I______
9. Is the patient following recommended treatment program? Yes No
PART VI: ESTIMATED TIME FOR RECOVERY 1. Patient Progress
None Regressed Minimal Improvement Significant Improvement Plateaued Resolved
2. Patient Prognosis Poor Good
3. Which of your patient’s occupational duties are currently being affected by his/her condition? _______________________________________
_________________________________________________________________________________________________________________
4. In your opinion, is the patient a suitable candidate for rehabilitation? Yes No If no, explain.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
5. If unable to determine, follow up in ________________ weeks or _____________ months.
6. What is being done (or is needed) in the following areas to help your patient return to a productive lifestyle? (Tick all appropriate boxes)
Physical conditioning Stress management/coping skills
Social confidence-building Vocational counseling Other _________________________________________________________
7. Any additional information or details that may have a significant impact on the patient’s recovery from this condition?
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Signature _____________________________________________________________ Date ___________________________________________
® Saskatchewan Blue Cross is a registered trade-mark of the Canadian Association of Blue Cross Plans, used under license by Medical Services Incorporated, an independent licensee. MSI 382 09/13
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