SOCIAL SECURITY--DISABILITITY DETERMINATION SERVICES
ADULT COMPLEX PSYCHOLOGICAL ASSESSMENT
The report should be submitted in a narrative form. This guideline should be
followed during the consultative exam to assure that all areas are covered
in your report.
1. Chief Complaint(s):
The chief complaint(s) alleged as a reason for not working. Include in the
section, a statement from the claimant regarding how his/her impairment or
condition limits his/her daily functioning.
2. History of Past and Present Illness:
This section of the examination report should describe and discuss:
a. Brief summary or list of background material/medical records reviewed
b. Psychiatric History
c. Past and Current Drug and Alcohol Use
d. Medical History
e. Social and Family History
f. Brief Work History
h. Military History
3. Mental Status:
Include in this section:
a. General Appearance
9 Well groomed or unkempt? What is the claimant wearing? Are clothes
appropriate for weather and situation?
9 Evidence of psychomotor agitation or retardation? Give examples.
b. Attitude and General Behavior
9 Is the claimant cooperative, irritable, belligerent etc.?
9 Is there any indication of malingering or factitious behavior? Explain.
c. Mood and Affect
9 How does the claimant describe his or her mood?
9 Is the claimant’s affect congruent with the stated mood? Explain.
d. Content of Thought
9 Are there any delusions?
9 Is the claimant suicidal? Homicidal? What leads you do this conclusion?
e. Stream of Mental Activity
9 Is speech normal or tangential or circumstantial?
9 Remote—can claimant remember past events?
9 Recent—can claimant remember 3/3 objects after 5 min?
9 Immediate—how well can the claimant do digit span back and forward?
Adult Complex Psychological Assessment
h. Fund of Knowledge
9 Is the claimant aware of current events? Give examples.
9 Does the c