Residual Functional Capacity Childhood Mental Disorders (Page 3 of 8) in pdf

Residual Functional Capacity Childhood Mental Disorders Page 3

MEDICAL AND FUNCTIONAL CAPACITY ASSESSMENT (CHILD)

SSI/SSD Review of Child’s Medical Impairments

How long have you treated the child and how often do you see him/her?

What is/are your diagnoses, and provide your estimated date of onset?

Please identify the clinical findings and objective signs supporting the diagnoses.

Please list your patient’s symptoms.

For an Anxiety Disorder Diagnosis:

How is the Anxiety Disorder diagnosis manifested in one or more of the following behaviors:

1. Excessive anxiety manifested when the child is separated, or separation is

threatened, from a parent or parent surrogate; or

2. Excessive and persistent avoidance of strangers; or

3. Persistent unrealistic or excessive anxiety and worry (apprehensive

expectation), accompanied by motor tension, autonomic hyperactivity, or

vigilance and scanning; or

4. A persistent irrational fear of a specific object, activity, or situation which

results in a compelling desire to avoid the dreaded object, activity, or situation; or

Mental Functional Assessment – Page Number 3

Residual Functional Capacity Childhood Mental Disorders Page 3