Read the guidance notesReview page 1 of this form carefully before doing anything else.
2
Provide your details to your doctorYour doctor will enter your name, address, date of birth and CRN when completing the form.
3
Send the form and relevant tables to your doctorThis form can be emailed to your doctor or printed and taken in. The relevant impairment tables should be emailed or printed and provided alongside it.
4
Ask the doctor to return it to youOnce the doctor has completed and signed the form, collect a copy for your records.
5
Ready to use as evidenceThe completed form can now be used as supporting medical evidence for your DSP claim.
🏥For the Doctor / Specialist
1
Read the guidance notesReview the guidance section carefully — it explains what DSP assessors are looking for and why detail matters.
2
Complete one form per conditionIf the patient has multiple conditions, a separate form should be completed for each one.
3
Ensure patient has provided the tablesCheck that the patient has supplied printed copies of the relevant impairment tables for your reference.
4
Sign and date the completed formPlease sign, date and stamp (if applicable) in the section provided at the end of the form.
5
Save as PDF or printIf completing digitally, save as a PDF before returning to the patient. Otherwise print and sign by hand.
When filling out, or creating, a report for a DSP claim, please be mindful that in order to qualify a person must be:
Formally diagnosed by a medical professional
Have exhausted all treatments that could provide a significant functional improvement within 2 years
Have functional impairments that align with a severe 20-point rating in one of the impairment tables
These points must be very clearly addressed for the best chance of success.
Using the relevant table rating criteria as sub-headings is an ideal way to address symptoms and impairments.
Medical Condition Details
Patient Details
Diagnosis
Is this diagnosis likely to be a lifelong condition?
Treatment *(great detail is not necessary)
Are there any reasonable (affordable, low risk, accessible, high success rate) treatments (including surgery) that are likely to produce a significant functional improvement in the next 2 years?
Note: Significant functional improvement is improvement that is likely to enable the person to undertake work in the next 2 years. Degenerative conditions that result in progressive and irreversible loss of function can be considered stabilised if reasonable treatment is not expected to result in significant functional improvement.
Are there any medical issues, such as mental health conditions, that affect the patient's ability to comply with treatment recommendations?
If yes, please provide details:
Prognosis
Is the condition likely to persist for more than 2 years?
Are the impairments related to this condition likely to persist more than 2 years?
Is there a likelihood of deterioration over time?
Does the patient have a terminal diagnosis?
Does the patient require nursing level care?
Symptoms and Functional Impact
Note: Only those impairments that are expected to persist for more than 2 years without significant functional improvement from current or planned treatment can be assessed under the impairment tables. Using the relevant table rating criteria as sub-headings is an ideal way to address symptoms and impairments.
Is this condition episodic or fluctuating?
If Yes, please describe:
Impairment Table Selection
Please select the most appropriate table(s) for the impairments related to this condition:
⚠ Please ensure the patient has provided a copy of the relevant tables with this document for appropriate referencing.
Impairment Table Rating(s)
Criteria to keep in mind when choosing a rating level:
Descriptors involving performing activities only apply if the person can do the activity normally and on a repetitive or habitual basis and not only once or rarely.
If an impairment is considered as falling between 2 impairment ratings, the lower of the 2 ratings is to be assigned and the higher rating must not be assigned unless all the descriptors for that level of impairment are satisfied.
When assessing impairments caused by conditions that have stabilised as episodic or fluctuating, a rating must be assigned which reflects the overall functional impact of those impairments, taking into account the severity, duration and frequency of the episodes or fluctuations as appropriate.
Table:
Table:
Table:
Table:
Work / Study Capacity
Does the patient have a capacity for work in an unsupported environment?
Note: It is expected that a person will be capable of reliably performing work on a sustainable basis, that is, for a reasonable period of time (i.e. 26 weeks) without requiring excessive sick leave or work absences (of four weeks or more, in total, in any given 26-week period).
Does the patient have a capacity to do training or formal study?
Additional Comments
Details of Health Professional Completing this Report
