PLEASE REVIEW ALL UPLOADS TO DO THIS CASE STUDY Medical Summary Report Template Use your agency’s letterhead and delete the guidance underneath each heading when submitting to DDS [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) 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 Adapt or Manage Oneself SUMMARY (Brief summary of the evidence provided, restating diagnoses provided in the introduction)
