Civil and Administrative Litigation Opinions for Self-Reppers
Medical Merits Review ===================== Client ___________________ Target Date _____________________ IMPAIRMENTS __Impairments____________Documents____________Duration___Verified? (Doc #, date, type, effect) _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ | | | | | | | | | _____________________________________________________________ DDP (HSR/ADL) _____________________________________________________________ By _____________/________ Years With _____ Dated ____________ _____________________________________________________________ ACTIVITIES OF DAILY LIVING _____________________________________________________________ | ADLs | _____________________________________________________________ | IEWS | _____________________________________________________________ | Comments | _____________________________________________________________ _____________________________________________________________ | Social | _____________________________________________________________ Notes: ______________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
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