Dss 486T Form – Fill Out and Use This PDF

DSS·486T (Rev. 9/91)

MEDICAL REPORT FOR DETERMINATION OF DISABILITY

Pages 1 and 2 MUST be completed in their entirety by ALL providers.

Subsequent pages must be completed only on the basis of impairment.

SECTION II • MEDICAL REPORT

NOTICE TO PHYSICIAN

This patient has made application (reapplication) for Disability Medicaid. Your cooperation in completing the form to show the pa- tient's current condition, focusing on both limitations and remaining capabilities, is requested. Your promptness will insure an early decision on the patient's application. Please return completed form to the agency in Section I above.

3. GENERAL FINDINGS:

DURATION Has the impairment(s) described above lasted, or can it/they be expected to last"for 1 year, or more? DYes D No

BODY SYSTEMS Pleaseindicate if the systems listed below are "normal"I"abnormal" or "present"/"absent". ("Abnormal" or "pre- sent" means patient's complaint, objective physical finding or atypical diagnostic test.) Where "abnormal"I"pre- sent" body systems are indicated, please complete the appropriate body system section in detail or submit a summary of your records which contain the required information. Please include operative notes if surgical

procedures have been performed.

--------------------------------------

·2·

DSS.486T (Rev. 9/91)

MUSCULOSKELETAL MEDICAL REPORT

3.History and Subsequent Course Include date and description of earliest symptoms; any history of trauma or joint inflammation, sensory, motor or reflex deficits.

4.Findings on Last Examination With Date

a. Please describe any current findings including presence or absence of muscle spasm, sensory, motor or reflex

deficits (including sites), with measurement of atrophy of both affected and unaffected extremity at same level for comparison and any swelling, heat or tenderness. List presence and describe location and severity of any con- tracture, ankylosis or subluxation.

b. Please indicate current limitations of motion in involved joints, with date of exam, using the attached "Range of

Motion Chart",

5.Fractures

a. If recent fracture(s) present, give date of occurrence, x-ray report findings, treatment course.

·3-

DSS.4Cl6T (Rev. 9/91)

1.Diagnosis

3.History and Current Findings

a. Date of first symptoms; inciting factor(s); description of character; location and radiation of pain.

b. Pertinent physical findings

(1) Site and severity of any sensory, motor, or reflex abnormalities.

(2)Please indicate limitation of movement of the spine on the attached "Range of Motion Chart".

(3)Any atrophy including actual circumferential measurements at a stated point above and below the knee or elbow given in inches or centimeters.

4.Lab Values

Laboratory findings, including dates and specific findings on x-ray (or copy of report), myelogram, or electro-diagnostic testing.

·5·

DSS·486T (Rev. 9191)

MUSCULOSKELETAL MEDICAL REPORT

Spinal Disorders (continued)

5.Treatment

Treatment including date, nature and result of any surgical procedure (please include copies of operative and patholog~ reports); medications prescribed with dosage, frequency and response.

6.Observation

Results of verifying observation (e.g., how patient gets on and off examining table, whether results of SLR are consis tent in other positions such as sitting, ability to walk on .heels or toes, arise from squatting position, etc.).

·6·

055·486T (Rev. 9/91)

RANGE OF MOTION CHART

Please complete ONLY the sections of this chart which illustrate joints that have less than full range of motion. Proce'ed by filling in the degree at which motion stops. Sections left blank will be considered normal.

Right Left _

E. External Rotation (0o-gOO)

Right Left _

Pronation

Supination

·7·

DSS·486T (Rev. 9191)

RANGE OF MOTION CHART (Continued)

45'

·8·---

3.History:

a.Etiology of impairment and signs and symptoms on first visit

b.Central visual acuity on first visit

1.Distant vision without correction

2.Distant vision with best correction

3.Near vision using Jaeger notation

c.Tension

4.Please give treatment and response, including dates, description, and residuals of any surgical procedures .

.g.

a.Current signs and symptoms

(1)Distant vision without correction

(2)Distant vision with best correction (include power of correcting lenses)

(3)Near vision using Jaeger notation

c. Tension

e.If visual field is constricted to 10° or less from the point of fixation, or the widest angle subtended to 20° or

6.Please enclose a copy of results of peripheral visual field testing by arc perimetry or Goldmann projection perimetry or complete the chart below.

Left

·10·

055-4861 (Rev. 9/91)

3.Please give findings on initial and most recent otolaryngological examination.

4.PIElase give results of pure·tone air and bone audiometry requested below. Please include the audiogram or a copy

1.500 HZ

2.1000 HZ

3.2000 HZ

5.PIElase give results of speech discrimination testing with best correction

a. Test used

e.Results of tympanometry

f.Hearing aid evaluation

11

6.Please give pertinent laboratory and x-ray findings. In cases of labyrinthine-vestibular disturbance, please give pos tiona I and caloric testing, electronystagmography, if performed.

7. In cases involving labyrinthine·vestibular disturbance, please answer the following:

3.Duration of attacks

4.Activities which precipitate attacks

d. Other symptoms (e.g., headaches, nausea and vomiting, syncope, increased deafness, immobility, etc.)

9. Please indicate treatment plan and response.

·12·

3.History. Include date and description of earliest symptoms (e.g., dyspnea, cough, hemoptysis, weight loss, etc.), and the nature, frequency and duration of episodes of respiratory distress. Include number of acute episodes which have occurred in the past year (with dates) requiring intensive hospital or emergency room care with intravenous or inhala- tion therapy.

4. Physical Findings

d. Findings on examination (e.g., presence of wheezing, rales, rhonchi, cyanosis, clubbing, edema of extremities, etc.)

e. Pleaseindicate degree of orthopnea. How many blocks can patient walk or flights of stairs climb without dyspnea?

·13·

DSS.486T (Rev. 9/91)

RESPIRATORY MEDICAL REPORT (continued)

5.Laboratory Findings with Dates

a.Results of ventilatory studies (FEV-1, MVV, VC) before and after bronchodilators or copy of report. Please enclosE actual spirographic tracings, and comment upon patient's cooperation.

b.Results of chest x-ray, bronchoscopy, blood gas studies (arterial PC02 and P02)

6.Please give treatment response

a. Date and description of any surgical procedure(s) with results

b.Names and dosages of any medications prescribed including dates prescribed and if patient still on prescribed medication

·14·

[.JSS-486T (Rev. 9/91)

CARDIOVASCULAR MEDICAL REPORT

Please give history including initial symptoms with dates first experienced, associated findings, present symptoms diagnosis (with AMA classification if possible).

-15-

DSS-486T (Rev. 9/91)

CARDIOVASCULAR MEDICAL REPORT (continued)

4.Please give positive and pertinent negative findings regarding subsequent course and most recent examination ir eluding dates, several blood pressure readings, funduscopic findings, heart rate, heart sounds, evidence of congestiv heart failure or peripheral vascular disease.

5.Please give.treatment and response including dates of any hospitalizations, surgical procedures, medications wit! dosages and frequency.

6.If a stress test was performed, state date and protocol used; summarize the treadmill findings; indicate if 85% 0 the submaximal heart rate was attained. if test was aborted, give the reason, inciuding stage and time in stage, tes was stopped (or submit copy of report).

7.Please enclose labeled copies of EKG'S on which diagnosis is based, giving standardization. Also include any perti nent 'holter monitor reports.

8.Pleasegive laboratory findings with dates including chest x-ray,angiography and catheterization or echocardiographi( reports. In cases of peripheral vascular disease, please give results of arteriography, Doppler or plethysmography 01 scans if performed (or submit copy of report)..

-16-

3.Please indicate if recurrent upper GI hemorrhage is evident, with etiology. Please indicate dates and results ofrepeate' he~atocrits.

4.If peptic ulcer disease is evident, please indicate what has been demonstrated by x·ray or endoscopy.

5.If weight loss has occurred, please describe pattern.

6.If chronic liver disease is evident, please indicate what procedures have been done. Please indicate bilirubin X 5 montl period.

7.If chronic colitis or regional enteritis are present, please give history, including operative findings, bariu~ studies biopsy, endoscopy report findings. Please indicate dates and results of repeated hematocrits. Indicate frequency 0 episodes of diarrhea, dehydration, pain and hospitalizations. If patient is being treated medically, please indicate ~edica tions. If being treated with Prednisone, indicate dosage and frequency.

6.Please give any pertinent lab data not included above.

·17·

OSS.4B6T (Rev. 9/91)

GENITO·URINARY MEDICAL REPORT

3.Please indicate if there is impairment of renal function including history of dialysis (acute or chronic) with frequencl transplant procedure report with post·op status report, serum creatinine for three month period. Is nephrotic syndroml present? Please indicate serum albumin and proteinuria.

4. Please indicate if· anorexia exists and describe weight loss pattern.

HEMIC AND LYMPHATIC MEDICAL REPORT

Please indicate chemotherapeutic treatment regimen.

3.History and Current Findings

a.In cases of chronic leukemia, chronic anemia, macroglobulinemia or heavy chain dise'ase, please indicate hematocri values from date of diagnosis forward.

b. In cases of chronic anemia, chronic thrombocytopenia, hereditary telangiectasia, coagulation defects, chronic leukemia, macroglobulinemia,- please indicate transfusion history.

c.If any other cases of hemic or lymphatic disorders exist, please give history and lab values from diagnosis datE forward.

-18-

4. Please indicc;lteprognosis

3.History and Current Findings

a. In cases of diabetes, please give complete history of episodes of acidosis, neuropathy, retinopathy and amputation

b. For all other endocrine disorders, please include diagnostic results and course to date.

·19·

OSS-486T (Rev. 9/91)

MULTIPLE BODY SYSTEMS MEDICAL REPORT

3.History and Current Findings

Please indicate the history and current findings regarding the following diagnoses: Hansen's disease; polyarteritis or periarteritis nodosa; systemic lupus erythematosus; scleroderma or progressive systemic sclerosis; obesity. Please include lab values and in cases of obesity, please indicate the following: weight hx, hx pain and limitation of ROM with x-ray reports, blood pressure readings, cardiac status if abnormal, pulmonary function studies if respiratory status is abnormal.

-20-

DSS-486T (Rev. 9/91)

NEUROLOGICAL MEDICAL REPORT

1.Diagnosis

3.Please give original chief complaint with initial history and findings.

4.Please describe subsequent course, including dates and details of any hospitalizations; give treatment with date started. response, any surgical procedures performed, medications with dosages.

5.Please give detailed findings on last examination including site and severity of any sensory, motor,

reflex, cerebellar, proprioceptive or cranial nerve deficits. Describe the effect upon gait, station, gross and dexteroul: movements. Are there any difficulties with communication?

6.Please give dates and results of significant laboratory findings (e.g., EEG, LP, brain scan, CAT scan, x·ray or patholog) report's, angiogram, etc.); if possible, please append copies of reports.

7.Please indicate prognosis.

·21-

055·486T (Rev. 9/91)

PSYCHIATRIC MEDICAL REPORT

Patienfs Na~e ~~~~~~~~~~~~~~~~~~~~I~S~S~N~~~~~~~~~~~~~~

1.Dibgnosis (including history, withdate(s) of hospitalization(s), findings on initial comprehensive mental status ex am, diagnosis according to APA terminology per DSM III. If dx of MR is given, please indicate 1.0. test results anc name of test administered.)

3. Clinical Course (including type of treat.ment, names and dosages of any drugs prescribed, response to treatment]

b. Speech, thought organization, thought content

c. Mood and affect

·22·

d. Sensorium and intellectual functions

·attention and concentration

·orientation

·memory

-information

"ability to perform calculations, serial sevens, etc. e. Insight and judgment

5.Please provide the results of any special testing performed (EEG,psychometric tests, etc.) as well as any informatior you may have concerning other medical impairments.

6.Current Functional Assessment

a.Activities of daily living (Please include a full description of how the patient spends a typical day with specifiC examples of grooming and hygiene, maintenance of residence, shopping, cooking, taking public transportation interests and hobbies, etc.)

b. Social functioning (Please include a full description with specific examples of capacity to interact appropriatel) and communicate effectively with family members, friends, neighbors, etc.)

-23-

055-41'\61 (Rev.9/91)

rSYCHIATRIC MEDICAL REPORT (continued)

7.Ability to Function in a Work Setting. Please describe in detail any difficulties in work or work-like settings (e.g. volunteel work, workshops, service in community groups), especially with regard to relationships with supervisor, relationshrp~ with peers and performance of job duties, (e.g., capacity to understand, carry out and remember instructions).

8. If suicidal features are present, describe in detail, and include whatever management steps have been taken.

9. Other Comments

·24·

-25-