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1. Date of your most recent examination of the
applicant. May 1, 1998
2. Is this your first examination of the individual?
Yes
No X
If yes, who is the regular attending
physician? ___________________
3. Based on your examination, describe any findings of a physical or mental disblity or impairment which, in your professional medical opinion, would prevent this applicant from demonstrating knowledge of basic English language and/or U.S. history and civics. Describe in detail. If applicant has a mental disability or impairment, please provide DSM diagnosis.
Mr. B. has vascular dementia secondary to arterial hypertension and heart disease, DSM IV 290.40. He was diagnosed in this office four years ago. Symptoms of his dementia include memory impairment (an impaired ability to learn new information or recall previously learned information), and cognitive disturbances, including an impairment of executive functioning, planning, sequencing, organizing and abstracting information. As a result of these symtoms, Mr. B. does not have the ability to learn a new language or to recall what he may have learned in the past. Mr. B. is unable to pass the written or spoken English tests or the U. S. history and civics test in order to naturalize.
4. Did the applicants disability or impairment result from the illegal use of drugs? If the applicant is developmentally disabled, did this condition first manifest itself before age 22? Please explain.
Patient's disability did not result from the use of alcohol or the illegal use of drugs.
5. What is the duration of the applicant's disability or impairment? Is it temporary (less than 12 months) or permanent. Explain.
Mr. B.'s dementia has existed for four years and is irreversable and progressive.
6. Please provide your medical specialty. If you are not specialized, provide your medical experience and other qualifications that permit you to make this assessment.
Family practice. The training for this primary care specialty includes training in thr primary care aspects of psychiatry and geriatrics as they pertain to Alzheimer's disease. Diagnosing and treating a patient with Alzheimer's disease is within routine practice of this specialty.`m