NDIS Access Request – GP Supporting Evidence Template
Patient Details:
- Name: John Smith
- Date of Birth: 12/03/1980
- Address: 123 Main Street, Anytown, NSW 2000
Treating Professional Details:
- Name: Dr. Jane Doe
- Qualification(s): MBBS, FRACGP
- Provider Number: 1234567A
- Practice Address: The Family Practice, 456 Oak Avenue, Anytown, NSW 2000
- Contact Number: 02 9876 5432
- Email: jane.doe@email.com
- Duration of Treatment: 5 years
Primary Disability:
- Diagnosis: Major Depressive Disorder
- Date of Diagnosis: 15/06/2018
- Is the condition permanent? Yes
- Is the condition likely to be lifelong? Yes
Secondary Disabilities (if any):
- Diagnosis: Generalised Anxiety Disorder
Medical History:
- Relevant medical and surgical history: Appendectomy in 2010.
- Relevant family history: Father with history of depression.
- Relevant social history: Smoker, 10 cigarettes per day.
- Allergies and reactions: NKDA
- Current medications: Sertraline 100mg daily, Clonazepam 0.5mg as required.
Functional Impact:
- Mobility: No significant impact.
- Communication: No significant impact.
- Social Interaction: Difficulty maintaining relationships and social isolation.
- Learning: Difficulty concentrating and impaired memory.
- Self-Care: No significant impact.
- Self-Management: Difficulty managing finances and attending appointments.
Treatment History:
- Previous Treatments: CBT, unsuccessful.
- Current Treatments: Sertraline and Clonazepam, with partial response.
- Future Treatment Options: Referral to a psychiatrist for review of medication and consideration of ECT.
Additional Information:
- The patient requires support with daily living activities due to the impact of their mental health conditions.
Declaration:
I, Dr. Jane Doe, confirm that the above information is accurate to the best of my knowledge and based on my professional assessment of John Smith.
Signature:
Date: 01/11/2024
