Medical Summary Report

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Medical Summary Report Template

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each heading when submitting to DDS

ACME WRITERS

[Insert DDS Address/Examiner if known]

NAME:

SSN:

DOB:

Dear _________:

INTRODUCTION

(The applicant’s physical description, including their behavior, mannerisms, and dress; all of the applicant’s physical and mental health diagnoses; information/observations that illustrate the applicant’s symptoms and functioning)

PERSONAL HISTORY

(Including abuse/trauma history, educational history, and legal history as they relate to the applicant’s symptoms and functioning)

OCCUPATIONAL HISTORY

(Employment and military history for the past 15 years; include all jobs, reasons for leaving, job skills, problems with task completion and relationships with supervisors and co-workers; describe how this relates to the applicant’s symptoms and functioning)

ACME WRITERS

SUBSTANCE USE

(Substance use history and treatment, including reasons for use, impact of use, treatment history, and any periods of sobriety; describe the applicant’s symptoms while sober)

PHYSICAL HEALTH HISTORY

(Brief summary of the applicant’s symptoms and treatment for physical health conditions at all providers including context for treatment, diagnoses, medications and side effects)

PSYCHIATRIC HISTORY

(Brief summary of the applicant’s symptoms and treatment for mental health conditions at all providers including context for treatment, diagnoses, and medications and side effects)

FUNCTIONAL INFORMATION

(Address all four areas of functioning using detailed examples and quotes to describe how the applicant’s symptoms impact his/her ability to function)

Understand, Remember, or Apply Information

Interact with Others

Concentrate, Persist, or Maintain Pace

ACME WRITERS

 

Adapt or Manage Oneself

SUMMARY

(Brief summary of the evidence provided, restating diagnoses provided in the introduction)

                                                                                                                        ACME Writers