Affective Disorders-Adults
                                                                          (12.04)


                                          
SECTION A: Medically documented persistence, either continuous or intermittent, of one
of the following two subsections:

1.  DEPRESSIVE SYNDROME CHARACTERIZED BY AT LEAST FOUR OF THE FOLLOWING:
                                        
                                                                                                           Present   Absent  Insufficient 
                                                                                                                                         Evidence

a.  Anhedonia or pervasive loss of interest in almost
     all activities                                                                                  ______    _____   ________

b.  Appetite disturbance with change in weight                               ______    _____   ________

c.  Sleep disturbance                                                                        ______    _____   ________

d.  Psychomotor agitation or retardation                                        ______    _____   ________

e.  Decreased energy                                                                      ______    _____   ________

f.  Feelings of guilt or worthlessness                                              ______    _____   ________

g.  Difficulty concentrating or thinking                                           ______    _____   ________

h.  Thoughts of suicide                                                                     ______    _____   ________

I.  Hallucinations, delusions, or paranoid thinking                         ______    _____   ________


2.  MANIC SYNDROME CHARACTERIZED BY AT LEAST THREE OF THE FOLLOWING:

                                                                                                         Present   Absent  Insufficient 
                                                                                                                                       Evidence
                                            

a.  Hyperactivity                                                                              ______    _____   ________

b.  Pressure of Speech                                                                     ______    _____   ________

c.  Flight of Ideas                                                                             ______    _____   ________

d.  Inflated self-esteem                                                                    ______    _____   ________

e.  Decreased need for sleep                                                          ______    _____   ________

f.  Easy distractability                                                                     ______    _____   ________

g.  Involvement in activities which have a high
probability of painful consequences which are
not recognized                                                                                 ______    _____   ________
                                                                           
h.  Hallucinations, delusions, or paranoid thinking                       ______    _____   ________

OR

                                                                                                           Present   Absent  Insufficient 
                                                                                                                                         Evidence

Bipolar syndrome with a history of episodic periods
manifested by the full symptomatic picture of both
manic and depressive syndromes (and currently
characterized by either/or both syndromes)                                    ______    _____   ________

AND

SECTION B: RESULTING IN AT LEAST TWO OF THE FOLLOWING:

                                                                                                             Present   Absent  Insufficient 
                                                                                                                                           Evidence

1.  Marked Restrictions of activities                    
of daily living:                                                                                      ______    _____   ________     

2.  Marked difficulties in maintaining
social functioning:                                                                               ______    _____   ________
  
3.  Deficiencies of concentration,
persistence, or pace resulting in
frequent failure to complete tasks
in a timely manner
(in work settings or elsewhere):                                                         ______    _____   ________

4.  Repeated episodes of deterioration
or decompensation in work or
work-like settings which cause the
individual to withdraw from that
situation or to experience
exacerbation of signs and symptoms
(which may include deterioration
of adaptive behaviors:                                                                       ______    _____   ________     
         


Please provide sources of information for above findings.  It is critical these
sources of information be provided otherwise the findings will not be seriously
considered by the social security administration.  Such sources may be, but are
not limited to, neuropsychological testing, laboratory tests, clinical
observations, progress notes, reports, etc.   
 
Identify or attach sources of information to support findings.











(Sources of information or attachments to support findings-continued) 






___________________________________               ________________________
 Printed Name                                                                          Date


___________________________________
 Signature


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 Speciality (Neuropsychologist, Psychiatrist, Psychologist, Neurologist etc.)