Page 704

3. Based on your knowledge of the individual’s medical condition, list any limitations that would affect the individual’s ability to participate in employment and training activities. □ Physical Limitations: _______________________________________________________________________________ □ Mental Health Limitations: __________________________________________________________________________ □ Other Limitations Not Listed Above: __________________________________________________________________ 4. Do you recommend that this individual apply for SSI (Supplemental Security Income) or SSDI (Social Security Disability Insurance) benefits at this time? □ Yes □ No

DIAGNOSIS AND TREATMENT: 5. Please indicate the primary medical reason for the individual’s inability to participate in employment and training activities, or to participate with modifications and/or limitations, in the “primary diagnosis” space below. Primary Diagnosis: ___________________________________________________________________________________ If other medical issues contribute to the individual’s inability to participate in employment and training activities, or to participate with modifications and/or limitations, please record those in “secondary diagnosis” space below. Secondary Diagnosis: _________________________________________________________________________________ 6. Would reviewing this form jeopardize the patient’s health or well-being? □Yes □ No

COMPLIANCE: 7. If physical therapy, counseling, medication or other treatments were prescribed, is the individual complying? □ Yes □ No □ Don’t know

8. If the individual is not complying with recommendations, are you aware of the reason for not complying? □ Yes □ No □ Don’t know 9. Does the individual’s condition hinder their ability to care for children? □ Yes □ No REFERRALS: 10. Does the individual require additional evaluation and/or assessment to determine current and/or future functioning?

□ Yes □ No If yes, by whom: _________________________________________________

Field or area of expertise: _____________________ Date referred: _______________________________ 032-03-1040-11-eng (10/22)