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
Primary Condition: Degenerative Disc Disease
Secondary Conditions:
Medications:
Gabapentin 300mg, 3 times daily
Cymbalta 60mg, once daily
Surgical History:
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.
Mobility: Reduced; requires a cane for ambulation.
Activities of Daily Living (ADL):
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.
Support System:
Primary support from spouse, Jane Everett.
Family involved in ongoing emotional and practical support.
Mental Health Treatment: Engaged in cognitive behavioral therapy since 2058.
Recommendations
Thomas should be considered for disability benefits due to his medical conditions and limitations.
Continued engagement in physiotherapy to improve pain management and mobility.
Regularly consult mental health professionals to manage ongoing depression.
Explore assistive devices and home modifications to aid with daily functioning.
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