gp support letter

Hiya,
It was good of the CAB to provide a 'form. to fill in via your GP.
I was wondering if this was a form that your CAB produced for the area in which you live or if it was a generic form./ Perhaps if it a form specific to your CAB perhaps you could get it downloaded on this site to help other CAB/Welfare people and for us here to use too.

gosh I will try, brain allowing
I scanned it and deleted all my info. If this is wrong em... help





MEDICAL REPORT


G.P. Name and Address:

Patient's Name and Address

(Please sign at the bottom of each page, Thank you)
1. Please detail the diagnosis/es for this patient and the prognosis.








2. What medication or treatment is being given?








Medical Report Cont.. ...
3. Please detail the patient's medical history over the past 2 years - copies of his/her notes
and correspondence for this period will suffice.




4. From your experience and knowledge of the patient please outline the main physical and
mental limitations they face.





5. In your opinion is the patient :
Capable of work? YES / NO
Capable of living entirely independently? YES / NO
Capable of walking 50 metres without stopping YES / NO

Signature of G.P:

Date: -
GP Name:

Many thanks
xxxx