ANXIETY RELATED DISORDERS-ADULTS
                             (12.06)


THE REQUIREMENTS ARE MET WHEN BOTH SECTIONS A AND C ARE MET OR SECTIONS A AND B ARE MET.

SECTION A: MEDICALLY DOCUMENTED FINDINGS DEMONSTRATED IN ANY ONE OF THE FOUR ITEMS
LISTED BELOW FOR THIS SECTION:

1.  Generalized persistent anxiety accompanied by three out of four of the following
signs or symptoms:
                                                     Present  Absent   Insufficient   
                                                                       Evidence

Motor tension                                         _______  ______  ___________

Autonomic hyperactivity                               _______  ______  ___________

Apprehensive expectation                              _______  ______  ___________

Vigilance and scanning                                _______  ______  ___________

OR

2.  A persistent irrational fear of a specific
object, activity, or situation which results in a 
compelling desire to avoid the dreaded object,
activity, or situation                                _______  ______  ___________

3.  Recurrent obsessions or compulsions which are a 
source of marked distress                             _______  ______  ___________

4.  Recurrent and intrusive recollections of a
traumatic experience which are a source of
marked distress                                       _______  ______  ___________

AND

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

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):                                        ______    _____   ________







                                          





                                                     Present  Absent Insufficient  
                                                                        Evidence




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:                               ______   _____  ________     


OR

SECTION C: Resulting in the complete inability
to function independently outside the area of
one's home                                            ______    _____   ________ 

  
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


___________________________________
 Speciality (Neuropsychologist, Physician, Psychologist, Neurologist etc.)