AISH Application Medical Report

AISH Application Medical Report **Confidential** **Section A: Applicant Information** * **Name of Applicant:** Jane Doe * **Date of Birth:** 15 January 1978 * **Alberta Personal Health Number:** 1234-5678-9012 * **Current Address:** 123 Main Street, Anytown, AB T1A 1A1 **Section B: Medical History** * **Primary Diagnoses:** Chronic Migraines with Aura, Fibromyalgia, Major Depressive Disorder (recurrent, severe without psychotic features) * **Date of Onset:** Migraines: January 2005; Fibromyalgia: March 2010; MDD: June 2012 * **Secondary Diagnoses (if any):** Irritable Bowel Syndrome (IBS) * **Date of Onset:** September 2008 * **Past Medical History:** History of concussion (2003), appendectomy (1995) * **Current Medications:** Topiramate 50mg BID, Amitriptyline 25mg QHS, Duloxetine 60mg OD, Sumatriptan 50mg PRN, Naproxen 220mg PRN * **Allergies:** Penicillin (rash) * **Relevant Social History:** Lives alone, unable to work due to chronic pain and fatigue, limited social interaction, no current substance abuse issues. **Section C: Functional Impairments** * **Impact of Conditions on Daily Living:** Ms. Doe experiences significant limitations in her ability to perform daily activities due to chronic pain, fatigue, and cognitive dysfunction associated with her migraines and fibromyalgia. She reports severe headaches occurring 3-4 times per week, lasting 24-72 hours, often accompanied by photophobia, phonophobia, and nausea, rendering her unable to leave her bed. Fibromyalgia pain is widespread, impacting sleep and physical activity. Her depressive disorder further exacerbates her fatigue and lack of motivation. * **Ability to Perform Activities of Daily Living (ADLs):** * **Bathing:** Requires frequent breaks, difficulty standing for extended periods. * **Dressing:** Slow, especially with fine motor tasks due to hand pain. * **Eating:** Generally independent, but meal preparation is challenging on bad days. * **Toileting:** Independent. * **Continence:** Independent. * **Mobility:** Limited by pain and fatigue. Can walk short distances indoors but struggles with stairs and prolonged standing/walking. Uses a cane occasionally for balance. * **Ability to Perform Instrumental Activities of Daily Living (IADLs):** * **Shopping:** Unable to manage grocery shopping independently due to fatigue and pain. Relies on family for assistance. * **Meal Preparation:** Struggles with standing, lifting, and repetitive motions required for cooking. Often relies on pre-made meals or assistance. * **Housekeeping:** Unable to perform regular housekeeping; requires external support. * **Managing Finances:** Independent with bill payment but struggles with complex financial planning due to cognitive fog during migraine episodes. * **Transportation:** Unable to drive safely during migraine episodes; relies on public transport or family for appointments. * **Medication Management:** Generally compliant, but occasionally misses doses during severe migraine attacks. * **Cognitive and Emotional Functioning:** Experiences significant 'brain fog' during and after migraine episodes, impacting concentration, memory, and processing speed. Mood is often low, with anhedonia and periods of increased anxiety, consistent with her diagnosis of MDD. Limited social engagement due to symptoms. **Section D: Prognosis and Treatment** * **Current Treatment Plan:** Ongoing pharmacological management as listed above. Physiotherapy for fibromyalgia pain (currently attending twice monthly). Regular follow-ups with her General Practitioner, Neurologist, and Psychiatrist. Psychotherapy for depression (weekly sessions). * **Response to Treatment:** Partial response to migraine prophylaxis, but breakthrough headaches remain frequent and severe. Fibromyalgia pain management is challenging, with fluctuating efficacy of current treatments. Depression shows some improvement with medication and therapy, but relapses are common, especially during periods of increased pain. * **Expected Duration of Impairments:** The chronic nature of Ms. Doe's conditions (migraines, fibromyalgia, and recurrent depression) suggests that her impairments are likely to be long-term, possibly lifelong. While symptoms may fluctuate, a significant return to full functional capacity is not anticipated given the chronicity and severity of her conditions and previous treatment responses. **Section E: Physician's Statement** * **Physician Name:** Dr. Sarah Jenkins * **Clinic Name:** City Medical Centre * **Address:** 456 Oak Avenue, Anytown, AB T1B 2B2 * **Phone Number:** (555) 123-4567 * **Date of Report:** 1 November 2024 I confirm that the information provided in this report accurately reflects my professional medical opinion regarding Jane Doe's health status and functional limitations. Based on her diagnoses of Chronic Migraines with Aura, Fibromyalgia, and Major Depressive Disorder, her ability to perform daily activities and engage in gainful employment is severely and persistently impaired. She meets the medical criteria for a disability designation.