J-11 Physicians Summary Report.pdf

World Trade Center Physician Summary Report

Patient Name: MemberID: Interview Date: 12/30/1899

To the treating physician:

The following report represents a summary of the pertinent positive and negative responses to a 43 page Comprehensive Medical History questionaire having 1500 possible responses. This summary is provided to assist you as you acquire your medical history. Should you have any questions about this report, please contact the World Trade Center National Responder Health Program at 1-877-498-2911 and ask to speak to the Medical Operations department.

Chief Complaint Did the patient have a Chief Complaint or a specific medical Insurance Concern?

Physician Notes:

Medical History

History of Present Illness Does the patient have any current significant symptoms, conditions, testing/procedures?

Pulmonary

Physician Notes:

Cardiovascular

ChestBurningQuestion ChestPressure ChestPain Heart Palpitations or

Irregular Heart Beat

Did this symptom worsen in frequency or severity over the past 12 months?

When did you last have the symptom?

Do you have the symptoms at rest?

Do you get the symptom when you walk up a hill in a hurry?

Do you get the symptom when you are walking at an ordinary pace on level ground?

Did you see a doctor or health professional for the symptom?

Do/Did you take any medications for the symptom?

If you take/took medicine and/or underwent treatment for symptom for at least 4 weeks, do you think that it helps/helped?

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Physician Notes:

Gastro-intestinal

Physician Notes:

Musculoskeletal

Physician Notes:

Does the patient have any additional significant symptoms, conditions, testing /procedures? Review of Systems

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Past Medical History [Currently known medical conditions and relevant procedural history]

Physician Notes:

Occupational History

Physician Notes:

Family History

Physician Notes:

Medications

Physician Notes:

Allergies

Physician Notes:

Smoking And Tobacco

Physician Notes:

Testing

Results

CBC

Chemistry

Urinalysis

Spirometry

Chest X-Ray

Does the patient have any abnormal testing results?

[append lab test results and interpretation]

□Yes (elaborate in the space provided below)

□ No

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Mental Health [see Appendix A for complete list of patient responses]

Captures health-related quality of life information. This helps to prompt the examiner about areas that may need further discussion during the interview -the purpose of further discussion is to assess the need for further professional help. Information gleaned may assist the examiner in making a competent referral for clinical mental health evaluation. Helpful to compare to prior answers during previous monitoring exams to assess trends over time

(especially with respect to chronic illness or issues that interfere with trauma recovery).

Short Form Health Survey - 12

Captures functional impairment and can be used to assess response to treatment - which can be used for longitudinal assessment as a continuous scale.

Sheehan's Disability Scale

Recent Life Experiences

Useful information to further clarify changes in quality of life and providing insights about changes in reported symptoms or functioning. Provides key issues that assist with referrals.

PTSD Symptom Checklist

Brief Patient Health Questionnaire for Panic Disorder

Brief Patient Health Questionnaire for Generalized Anxiety Disorder

Brief Patient Health Questionnaire for Depression

Alcohol use Disorder Identification Test

Additional help requested

Enables the WTC responder to indicate where problems might exist in a less structured fashion- provides the cues for areas to inquire about in the clinical mental health evaluation.

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World Trade Center Covered Conditions

Physical Health Mental Health

Aerodigestive Disorders

• Interstitial lung diseases

• Chronic Respiratory Disorder -Fumes/Vapors

• Asthma

• Reactive Airways Dysfunction Syndrome (RADS)

• WTC-Exacerbated Chronic Obstructive Pulmonary

Disease

• Chronic Cough Syndrome

• Upper Airway Hyperreactivity

• Chronic Rhinosinusitis

• Chronic Nasopharyngitis

• Chronic Laryngitis

• Gastro-Esophageal Reflux Disorder (GERD)

• Sleep Apnea Exacerbated By Or Related To The Above

Conditions

Musculoskeletal Disorders

• Low Back Pain

• Carpal Tunnel Syndrome (CTS)

• Other Musculoskeletal Disorders

Mood Disorders

• Major Depressive Disorder

• Depression (not otherwise specified)

• Dysthymic Disorder

Anxiety Disorders

• Panic Disorder

• Post Traumatic Stress Disorder (PTSD)

• Generalized Anxiety Disorder

• Anxiety Disorder (not otherwise specified)

• Acute Stress Disorder

Adjustment Problems

• Adjustment Disorder

• “V codes” (corresponding to clinical interventions)

Substance Misuse

• Alcohol abuse

• Alcohol dependence

Does this person have evidence of a World Trade Center covered condition?

Conditon

Referrals

Additonal Testng

Medicatons

Condition

Referrals

Additional Testing

Medications

Advice and Patient Counseling

[append carbon copy of referral paperwork - red for WTC related, blue for non-related referrals; if treatment rendered, like Rx - be sure appropriate 1500 bill and registration done]

Condition

Referrals

Additional Testing

Medications

Advice and Patient Counseling

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Condition

Referrals

Additional Testing

Medications

Advice and Patient Counseling

Condition

Referrals

Additional Testing

Medications

Advice and Patient Counseling

Conditon

Referrals

Additonal Testng

Medicatons

Additional Comments

Physician Name (printed) Physician Signature Date

Type of Visit: □Initial □Follow-up Referral for Treatment: □Yes □ No

Does this person have evidance of physical health or mental health condition that is not World Trade Center that requires further follow-up?

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Appendix A: Mental Health Questionnaire Patient Responses

Short Form Health Survey - 12

Sheehan's Disability Scale

Recent Life Experiences

PTSD Symptom Checklist

Brief Patient Health Questionnaire for Panic Disorder

Brief Patient Health Questionnaire for Generalized Anxiety Disorder

Brief Patient Health Questionnaire for Depression

Alcohol use Disorder Identification Test

Additional help requested

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