Statement Of Expert Evaluation Page 2
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4CASE NO. ___________________________
4.
Is the individual presently under medication?
Yes
No
If yes, what is the medication, dosage,
and purpose? _______________________________________________________________________________
__________________________________________________________________________________________
Are there any signs of physical and/or mental impairments caused by the medications themselves? ___________
__________________________________________________________________________________________
5.
Is the individual mentally impaired?
Yes
No
If yes, indicate the diagnosis below:
Mental Retardation/Developmental Disabilities:
Profound
Severe
Moderate
Mild
Mental Illness: Type and Severity __________________________________________________________
__________________________________________________________________________________________
Substance Abuse: Description _____________________________________________________________
___________________________________________________________________________________________
Dementia: Description ___________________________________________________________________
___________________________________________________________________________________________
Please provide additional comments and test scores if available. (Continue comments on page 4): ____________
___________________________________________________________________________________________
6.
During the examination did you notice an impairment of the individual’s:
a.
Orientation
Yes
No
Unknown
b.
Speech
Yes
No
Unknown
c.
Motor Behavior
Yes
No
Unknown
d.
Thought Process
Yes
No
Unknown
e.
Affect
Yes
No
Unknown
f.
Memory
Yes
No
Unknown
g.
Concentration and comprehension
Yes
No
Unknown
h.
Judgment
Yes
No
Unknown
7.
Please describe any impairment identified in question six. (Continue commonest on page 4).
___________________________________________________________________________________________
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