Form Tr 0056 – Fill Out and Use This PDF

Tennessee Consolidated Retirement System

502 Deaderick Street, Nashville, Tennessee 37243-0201

615-253-8693

Attending Physician's Report of Disability*

*Attention applicant and physician:

1.This is an authorization requested by the applicant in order that discussion of any and all information concerning the applicant's disability may be freely given to the TCRS.

2.The expense of furnishing this information must be paid by the applicant.

3.In addition to the completion of this form, the physician is requested to attach all office notes, hospital summaries, test results and any other medical information available.

Part I - To be filled in and signed by applicant.

1.

Applicant's Name: (last)

(first)

(middle)

2.

Address: (street)

(city)

(state)

(zip)

Part II - To be completed by physician, psychiatrist, or psychologist.

1a.	Current Height:	Feet	Inches	1b.	Current Weight:		Pounds
2.	You were first consulted in present illness:			(month)	(day)		(year)
					/		/
3a.	You are now attending the applicant:		(	) Yes	(	) No
3b. If not, state why:

Diagnosis

4.Primary impairments:

5.Secondary impairments:

Complete only the parts that are applicable. Give results or description.

Musculoskeletal System

6.X-ray findings:

7.Limitation of motion and the degree:

8.Comment on history of pain, swelling and stiffness:

Respiratory System

9.Chest x-ray findings:

10.Pulmonary function/arterial blood/gas studies:

11.In the case of pulmonary tuberculosis, provide sputum culture results:

12.Cyanosis/dyspnea:

TR-0056 (Revised 1/03)

RDA-413

Part II cont'd- To be completed by physician, psychiatrist, or psychologist.

Cardiovascular System

13.EKG's/enzyme studies:

14.Blood pressure readings:

15.Chest x-ray, including cardio-thoracic ratio:

16.Chest pain and medication used to relieve pain:

17.Edema, pigmentation, cyanosis or ulceration:

18.End-organ damage as a result of hypertension:

19.Indicate New York Heart Classification:

Mental Disorders

20.Impairment of memory, judgement/ability to perform calculations:

21.Reduction in daily activities, interests, personal habits and ability to relate to others:

22	Ability to relate to and communicate with supervisors and co-workers in a work situation:	(	) Yes	(	) No
	Explain:
Hearing
23.	Results of audiological evaluation (with hearing aid):

Visual

24. Best corrected visual acuity and visual fields:

Digestive

25. Liver studies, x-ray findings, endoscopy/barium enema studies, weight loss:

Genito-Urinary

26. BUN/creatine clearance, report of dialysis treatment:

Hemic and Lymphatic

27. Complete blood count:

Endocrine

28. Diabetes, evidence of neuropathy, acidosis, amputations/opthalmological changes:

Neurological

29. EEG and describe motor limitations:

Neoplasms

30. Biopsy and operative reports, severity and extent of lesion:

Prognosis

31a. Based on your recommended treatment, give degree of improvement that can reasonably be anticipated along with approximate period of time required to achieve this improvement:

31b.The impairment has or is expected to last 12 continuous months:					(	) Yes	(	) No
32. The impairment prevents performance of past work:				(	) Yes		(	) No
33a. The impairment prevents engagement in all other gainful employment.:						(	) Yes	(	) No
33b.If not, indicate type of work the applicant is capable of performing:
(	) Heavy	(	) Medium	(	) Light		(	) Sedentary

34. Include any hospitalization records, including discharge summary:

TR-0056 (Revised 1/03)

RDA-413