(Date)

Patient:___________________________________________________

SSN:    ___________________________________________________


Dx:     ___________________________________________________



          
                             Organic Mental Disorder


Psychological and behavioral abnormalities associated with a dysfunction of the brain. 
History and physical examination or laboratory tests demonstrate the presence of a
specific organic factor judged to be etiologically related to the abnormal mental state
and loss of previously acquired functional abilities.

Demonstration of a loss of specific cognitive abilities or affective changes and the
medically documented persistence of at least one of the following: 

SECTION A
                                     Present  Absent  Insufficient 
                                                      Evidence

Disorientation to time and place:         ______    _____   _____

Memory impairment, either
short-term (inability to learn
new information), intermediate, or
long-term (inability to remember
information that was known sometime
in the past):                             ______    _____   _____

Perceptual or thinking
disturbances (e.g., hallucinations,
delusions):                               ______    _____   _____

Change in personality:                    ______    _____   _____

Disturbance in mood:                      ______    _____   _____

Emotional lability (e.g., explosive
temper outbursts, sudden crying,
etc.) and impairment in impulse
control:                                  ______    _____   _____








                              Present   Absent  Insufficient
                                                      Evidence

Loss of measured intellectual
ability of at least 15 IQ points
from premorbid levels or overall
impairment index clearly within
the severely impaired range on               
neuropsychological testing, e.g.,
The Liria-Nebraska,
Halstead-Reitan, etc.:              ______    _____   _____


                              AND                           

SECTION B
          
MARKED Restrictions of activities   ______    _____   _____
of daily living:

MARKED difficulties in maintaining
social functioning:                 ______    _____   _____

Deficiencies of concentration,
persistence, or pace resulting in
FREQUENT FAILURE to complete tasks
in a timely manner
(in work settings or elsewhere):    ______    _____   _____

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:              ______    _____   _____ 

Other:                              ______    _____   _____

(Explain Other:______________________________________________________________


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, Neurologist etc.)