Blue Chip Medical Reviews Inc
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SELECT YOUR DOCTOR
Dr Wagner
Dr Kirshtein
Dr Kobeissi
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Select Location
(Required)
Queens
Brooklyn
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RE-EXAM
NF
WC
TIME IN
Hours
:
Minutes
AM
PM
AM/PM
NAME
(Required)
IME CO
DATE OF EVALUATION
MM slash DD slash YYYY
DATE OF INCIDENT
MM slash DD slash YYYY
AGE
GENDER
Male
Female
NAME OF INTERPRETER
RELATIONSHIP
INTERVIEWED IN
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Mother/Father Present
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Attorney Present
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Video /Audio taped
Taped by (name)
** MINORS ONLY: Current Living Situation: Lives with ( all that apply):
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Parents
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Mother
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Father
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Siblings
CURRENT GRADE
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Regular Classes
Special Ed
INITIAL PSYCHOLGICAL / PSYCHIATRIC SYMPTOMS:
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Initially Following
Gradual Over Time
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Denied any Psychiatric symptoms as a result of the MVA/work-related incident
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FLASHBOOKS
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Visuals
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Auditory
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Olfactory
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General Nervousness
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Increased Stress
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Worry
Worry About
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Nervousness:
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Driving a car
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Traveling in ______
Worry About
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Nervous to Cross the Street
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Having recurrent thoughts of the accident
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Having nightmares of the accident
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Depressed Mood
DUE TO:
Pain
Being out of work
Loss of Function
Unknown etiology
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Insomnia
DUE TO:
Pain
Anxiety
Headaches
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Irritability
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Panic Attacks
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Fatigue / Low Energy
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Anhedonia
RATING (severity of initial symptoms):
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Mild
Moderate
Marked
Severe
DRIVING/RESTRICTIONS (MVA):
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Avoided Driving / Traveling / Crossing Street
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WHY?? DUE TO (Check all that apply):
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Anxiety
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Pain
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Did not have access to a car
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Did not avoid Driving
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Traveling as a passenger following the accident, but
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Drove
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Traveled in car less often
INITIAL NEURO COMPLAINTS:
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None
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Short-term memory deficits
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Problems with Concentration
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Dizziness
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Headaches
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Blurred Vision
CURRENT PSYCHIATRIC MEDICATION(S):
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None
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Anti-anxiety
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Antidepressant
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Other Type
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Sleep Aid (OTC---Prescription)
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**ON PSYCHIATRIC MEDICATION SINCE:
PRESCRIBED BY :
CURRENTLY REPORTED PSYCHOLOGICAL/PSYCHIATRIC SYMPTOMS:
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Denies any Current Psychiatric symptoms as a result of the MVA
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Visual Flashbacks
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Auditory Flashbacks
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Olfactory Flashbacks
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General Nervousness
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General Worry
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General Stress
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Nervousness:
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Driving a car
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Traveling in ______
Worry About
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Nervous to cross the street
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Having continued thoughts of the accident
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Nightmares
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Depressed Mood
DUE TO:
Pain
Being out of Work
Loss of Function
Irritability
Unknown etiology
Fatigue/Low Energy
Anhedonia
Panic Attacks
CAUSES OF PANIC ATTACK
SEVERITY OF CURRENT SYMPTOMS:
Mild
Moderate
Marked
Severe
DRIVING/RESTRICTIONS
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Currently
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Drives or
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Travels in MV
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but less often
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Locally only
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with min difficulty
OR
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Continues to avoid
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Driving
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Traveling in a MV due to
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Anxiety
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Pain
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no access to a car
Other UNRELATED stressors that could be contributing to the claimant’s current symptoms (i.e., divorce, problems with family, work, evictions, deaths or sicknesses in family, etc.):
CURRENT NEUROLOGICAL COMPLAINTS
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NONE
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Short-term memory deficits
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Problems with Concentration
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Dizziness
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Headaches
PRIOR/SUBSEQUENT MEDICAL HISTORY
** UNRELATED TO THIS CLAIM**
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Psychiatric History: NONE
OUTPATIENT TREATMENT FOR:
Depression
Anxiety
Other
DATE OF TREATMENT
LENGTH OF TX
RECEIVED
Psychotherapy only
Medication only
Both Medication & Psychotherapy
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INPATIENT TREATMENT FOR:
Depression
Bipolar
Psychosis
Other
IF OTHER, SPECIFY
LENGTH OF INPATIENT TX
MOST RECENT HOSPITAL ADMISSION (NAME AND DATE)
EMPLOYMENT STATUS AT TIME OF ACCIDENT:
NONE
F/T
NONE
P/T
NONE
Unemployed
NONE
Disabled
NONE
Retired
NONE
Student
Job Type
EMPLOYMENT STATUS AT TIME OF ACCIDENT
JOB TYPE/ OCCUPATION
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DISABLED at time of accident
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UNEMPLOYED at time of accident
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DID YOU MISS WORK/SCHOOL?
Yes
No
IF YES, AMOUNT MISSED
RTW DATE
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Did not RTW since accident (or date)
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Continued to work until (date)
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CURRENT EMPLOYMENT STATUS
F/T
P/T
Unemployed
Retired
Student
WORKING AT
Same Job
Different Job
JOB TYPE/ OCCUPATION
RECEIVING WC BEN?
No
Yes (for this case)
Yes (for subsequent)
Yes (for prior case)
TYPICAL DAY:
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Attends treatment
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Child care
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Visits with Family/Friends
SHOPPING
Light
Minimal
COOKING/ CLEANING
Light
Minimal
LAUNDRY
Light
Minimal
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Attends church/temple
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Watches TV
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Reading
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Exercising
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Visits with Family
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Visit with Friends on occasion
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Stays at home much of the time
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Due to pain, the claimant receives help with daily chores.
PSYCHIATRIC EXAMINATION
APPEARANCE: Choose one from each line
APPEARANCE
Well-groomed
APPEARANCE
Disheveled
APPEARANCE
Malodorous
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Normal Weight
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Underweight
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Normal Weight
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Well Rested
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Appears Tired
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Appears stated age
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Appears younger than age
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Appears older than age
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Casual dress
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**wearing (brace or unusual):
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AMBULATES
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Without assistance
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With assistance of cane OR walker
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In wheelchair
CHOOSE ONE:
Severe pain discomfort
Some pain discomfort
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In no obvious pain discomfort or distress
EYE CONTACT
Good
Fair
Poor
ATTITUDE
Cooperative / Friendly
Resistant / Hostile
Indifferent / Apathetic
ESTIMATED INTELLIGENCE
Below Average
Low Average
Average
High average
PSYCHOMOTOR ACTIVITY
Within Normal limits
Agitation
Retardation
SPEECH FLOW
Normal
Pressured
Slurred
Mumbles
Stutters
THOUGHT PROCESS
Clear, Goal-Directed
Circumstantial
Tangential
COGNITIVE FUNCTIONING
Oriented to person, place, time, situation
Disoriented
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SUICIDAL IDEATION
Denied
Vague (no clear plan or intent)
Intent
COGNITIVE FUNCTIONING
No evidence of Delusions
Evidence of Delusion
HOMICIDAL IDEATION
Denied
Vague (no clear plan or intent)
Intent
PRECEPTUAL ABNORMALITIES
No evidence of Hallucinations
Depersonalization
Hallucinations
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**Please Be Sure To Question Claimant On Each Category**
CONCENTRATION: Spell WORLD Backwards: (20, 17, 14, 11, 8, 5, 2) Days of the Week Backwards: Sun, Sat, Fri, Thurs, Wed, Tues, Mon
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Good
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Fair
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Poor
COMPUTATIONAL ABILITY: 48 x 2=___ 39 - 11=___ 18 + 7=___ 21 ÷ 3=___ 49 ÷ 7=___ ¾ + ¼ =____
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Good
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Fair
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Poor
FUND OF KNOWLEDGE: Crnt. Prsdnt.___ Prev. Prsdnt. ___ 3 Oceans___ Columbus ___ H20____
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Good
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Fair
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Poor
ABSTRACT ABILITY: Penny Saved __ Strike/Iron __ Orange/Banana __ Table/Sofa___ North/West ____
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Good
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Fair
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Poor
RECENT MEMORY: Recall 3 words after 5-minute delay (Cat, Bicycle, Lamp): ____ out of ____ Ate for Dinner/Breakfast ___
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Good
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Fair
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Poor
REMOTE MEMORY: Name of High School/Elementary School___ (How is recall of past?)
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Good
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Fair
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Poor
INSIGHT
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Good
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Fair
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Poor
JUDGEMENT
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Good
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Fair
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Poor
AFFECT
Blunted
Labile
Anxious
Limited Range, non-reactive
Tearful
Limited Range, although reactive
Full Range, Calm & Reactive
MOOD
Euthymic
Dysphoric
Elated Judgment
Angry
Irritable
SELF-REPORTED MOOD
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Speaks of MVA (incident) in a neutral, calm manner
DIAGNOSIS / IMPRESSION
(Please indicate if symptoms are UNRELATED OR PRE-EXISTING to THIS accident/incident)
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Unremarkable psychiatric examination. The claimant failed to report or display any psychiatric symptoms as a result of the accident (NO DIAGNOSIS)
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Unremarkable psychiatric examination. The claimant failed to report or display any clinically significant psychiatric symptoms as a result of the accident and does not meet the clinical criteria for a DSM-V psychiatric disorder.
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That is, his / her initial reported complaints were of a mild and sub-clinical nature, were not excessive, and did not result in any functional limitations. (NO DIAGNOSIS)
Adjustment D/O w/ Depressed Mood:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Adjustment Disorder w/ Anxious Mood:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Adjustment D/O w/ Mixed Anxiety and Depressed Mood:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Post-Traumatic Stress Disorder:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Acute Stress Disorder:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Specific Phobia, Situational Type:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Major Depression:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
Depressive Disorder, NOS:
Resolved
Partially Resolved
Related
Unrelated
Pre-Existing
Exacerbated
OTHER
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CASUAL RELATIONSHIP:
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Not related
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Is related
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Symptoms are only partially causally related to the above-captioned motor vehicle accident / work-related incident. That is, the claimant has a
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PRE-EXISTING PSYCHIATRIC DISORDER that is
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AN UNRELATED STRESSOR
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contributing to (CR diagnosis not resolved)
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accounting for (CR diagnosis resolved) the current psychiatric symptoms
TREATMENT (CHOOSE ONE ONLY):
RELATED TO THE INCIDENT/ACCIDENT ONLY – NOT PRE-EXISTING/UNRELATED
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The claimant failed to report or display any psychiatric symptoms as a result of the accident / incident.
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SIGNIFICANT
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CURRENT
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CLINICALLY SIGNIFICANT)
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has reached a plateau/MMI in her / his treatment. It is my impression.
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is functioning at his/ her pre-accident level. And, as there are no current objective findings, it is my impression… that future psychiatric treatment, including psychotherapy and medication management, or psychological diagnostic testing are not reasonable, related, or necessary.
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Future psychiatric treatment IS reasonable, related, and necessary.
PSYCHOTHERAPY
continue
initiate
U
U
PSYCHIATRIC (medication management) TREATMENT
continue
initiate
U
U
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PALLIATIVE (WC ONLY & When asking for permanency): The claimant has reached a plateau in his / her treatment. He / She has reached maximum medical improvement within my specialty. However, the claimant should continue a palliative level of psychiatric care, including psychotherapy and medication management, once every 6 weeks.
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ADD ON ONLY: UNRELATED ISSUES : Comment is deferred with regards to treatment for the claimant’s
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unrelated psychopathology /
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pre-existing psychiatric disorder.
DISABILITY
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NO disability
THE CLAIMANT CAN DO WITHOUT ANY RESTRICTION.
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continue to work / school
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can work
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return to work / school
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Accident-related disability
THE CLAIMANT CAN DO WITHOUT ANY RESTRICTION.
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return to work / school
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can work
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continue to work / school
RESTRICTIONS
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On a part-time basis (four hours a day, five days a week) to minimize stress.
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More frequent breaks
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Restrictions:
U
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Avoid:
U
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Others
U
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TOTAL DISABILITY
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PERMANENT (IF APPLICABLE)
DUE TO:
Mood Instability / Irritability
Limited / Poor Attention / Concentration
Interpersonal Sensitivity
Lack of Energy
Lack of Motivation
Inability to cope with on the job stress
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ADD ON ONLY: UNRELATED ISSUES: With regards to the claimant’s disability status due to the unrelated pre-existing psychiatric disorder, I would defer comment.
TIME IN
Hours
:
Minutes
AM
PM
AM/PM
TIME OUT
Hours
:
Minutes
AM
PM
AM/PM
MEDS REVIEWED TIME
