Psychiatric Attending Physician Statement Form
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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
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
9. Current height
weight
recent fluctuations
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 _______________________________________________________________________________________________________
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