MENTAL INTERROGATORIES

RE: SS#:

For the following interrogatories, please evaluate the individuals capacity to sustain the enumerated activity over a normal work day and work week, on an ongoing basis. If there is no information on the limitation enumerated, please base your interrogatories on inferences which reasonably flow from the medical evidence and your medical expertise. If you still believe that there is no evidence of limitation in this category from which an assessment can be drawn or that the category is not applicable, please so indicate. 1. Do you consider the claimants ability to remember locations and work-like procedures as: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to understand and remember very short and simple instructions: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to understand and remember detailed instructions: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to carry out very short and simple instructions: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to carry out detailed instructions: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to maintain attention and concentration for extended periods: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to perform within a schedule, maintain regular attendance, and be punctual within customary tolerances: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to sustain an ordinary routine without special supervision unlimited:: unlimited / not significantly limited / moderately limited /

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Mental Interrogatories Page 2 or markedly limited?

Mental Interrogatories Page 3 9. Is the claimants ability to work in coordination with or proximity to others without being distracted by them: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to make simple work-related decisions: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to complete a normal work day and work week without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to interact appropriately with the general public: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to ask simple questions or request assistance: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to accept instructions and respond appropriately criticism from supervisors: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to respond appropriately to changes in the work setting: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to be aware of normal hazards and take appropriate precautions: unlimited / not significantly limited / moderately limited / or markedly limited? Is the claimants ability to travel in unfamiliar places or use public transportation: unlimited / not significantly limited / moderately limited / or markedly limited?

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Mental Interrogatories Page 4 20. Is the claimants ability to set realistic goals or make plans independent of other: unlimited / not significantly limited / moderately limited / or markedly limited? What are the primary signs and symptoms upon which you base the limitations found above, if any?

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___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 22. Does your assessment of the claimants mental condition significantly differ from the opinions of treating sources or from the claimants allegations? If so, please explain you basis for disagreement.

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 23. Would your patient have difficulty working at a regular job on a sustained basis? Yes ( ) No ( ) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 24. What is the first date that these limitations would be applicable?? _____________

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DSM-IV Multiaxial Evaluation: Axis I: Axis II: Axis III: Axis IV: ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

Axis V: Current GAF: ___________________________________________ Highest GAF: ___________________________________________

_______________ Date

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Printed/Typed Name: ____________________________________

Address:

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Please return to: