Disability Case Note Template
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Disability Case Note

Prepared By: [Your Name]

Company: [Your Company Name]

Client Information

  • Name: Thomas Everett

  • Date of Birth: March 14, 2000

  • Case Number: DCN-2060-4527

  • Address: 123 Main Street, Anytown, USA 12345

  • Date of Assessment: June 1, 2060

Referral Information

  • Source of Referral: Dr. Susan Clarke, Primary Care Physician

  • Reason for Referral: To assess eligibility for disability benefits due to chronic medical conditions impacting daily functioning.

Medical History

  1. Primary Condition: Degenerative Disc Disease

  2. Secondary Conditions:

    • Chronic Pain Syndrome

    • Depression due to chronic illness

  3. Medications:

    • Gabapentin 300mg, 3 times daily

    • Cymbalta 60mg, once daily

  4. Surgical History:

    • Lumbar Spinal Fusion - May 2055

Functional Assessment

Thomas Everett presented with significant limitations in physical functioning. He reported persistent lower back pain, rating an average daily pain level of 7 out of 10. Pain exacerbates with prolonged sitting or standing, limiting his ability to perform routine work-related activities.

  1. Mobility: Reduced; requires a cane for ambulation.

  2. Activities of Daily Living (ADL):

    • Struggles with household chores and personal care tasks due to pain and fatigue.

    • Is reliant on a spouse for transportation and shopping needs.

  3. Cognitive Functioning: No significant impairments noted; however, the client reports difficulty in concentrating due to pain and medication side effects.

Psycho-Social Evaluation

Thomas has experienced increased social withdrawal since his condition worsened, affecting his mood and overall mental health. He attends bi-weekly counseling sessions to manage his depression and anxiety related to his medical condition.

  1. Support System:

    • Primary support from spouse, Jane Everett.

    • Family involved in ongoing emotional and practical support.

  2. Mental Health Treatment: Engaged in cognitive behavioral therapy since 2058.

Recommendations

  1. Thomas should be considered for disability benefits due to his medical conditions and limitations.

  2. Continued engagement in physiotherapy to improve pain management and mobility.

  3. Regularly consult mental health professionals to manage ongoing depression.

  4. Explore assistive devices and home modifications to aid with daily functioning.

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