Report Of Physical Mental Examination Form – Fill Out and Use This PDF

INSTRUCTIONS FOR PHYSICIAN/LICENSED PSYCHIATRIC CLINIC IN COMPLETING

REPORT OF PHYSICAL/MENTALEXAMINATION (PA586)

Section II. Complete as indicated.

Section III. Medical information is required by the county assistance office (CAO) in determining whether a person qualifies for a certain category of assistance and can be considered employable. Your medical assessment and diagnosis of the individual’s functional capacity is needed so the CAO can make a decision on the person’s category of assistance and employability in the following manner:

1.Capacity Unlimited - the patient is determined to have no functional limitations, is not in need of health sustaining medication and is able to seek and maintain full-time gainful employment in a normal work environment with normal work schedules.

2.Capacity Unlimited with Accommodations - the patient is determined to be fully employable, provided that necessary accommodations are available to compensate for a physical or mental limitation and/or the need for health sustaining medication. Persons participating in a sheltered workshop program or supported employment more than 30 hours a week and requiring special accommodations to maintain employment may fit into this category.

Physical Limitations are defined as physical impairments resulting from a significant non-correctable hearing or vision loss, mobility problems, or any physiological disorder that must be regulated by medication.

Mental Limitations are defined as lack of touch with reality, anxiety or agitation under minor stress, depressed mood or social isolation due to emotional disturbances; inadequate responses to intellectual, emotional, social or physical demands due to limited intellectual capacity; or use of mind/mood altering drugs including alcohol.

Health Sustaining Medication is defined as pharmaceutical maintenance needed to enable a person to seek and maintain full-time gainful employment in a normal work environment. This sub-block can be checked in conjunction with accommodations needed for physical/mental limitations or when no other accommodations are needed other than health sustaining medication.

Physical or Mental Limitations or the need for health sustaining medication are indicated by a check-off in the appropriate block(s). Statements which substantiate and amplify the patient’s physical/mental limitations and identify the health sustaining medication and type(s) of accommodations required are entered in the “Comments” section of the form.

3.Capacity Limited - the patient is determined to have functional limitations which prevent full-time employment, but allow part-time employment up to 30 hours weekly. Persons participating in a sheltered workshop program or in supported employment limited to working 30 hours a week or less may fit into this category.

Physical Limitations - See above Mental Limitations - See above

Health SustainingMedication is defined as needing drug maintenance in order to seek and maintain part-time employment of up to 30 hours weekly.

Physical or Mental Limitations - See above

4.Temporarily Incapacitated - the patient is determined temporarily unemployable due to a present incapacity or temporary symptomatic problem. Please indicate the expected duration of the temporary incapacity and whether a reassessment of the incapacity is needed after this date. Your statement in the “Comments” section will assist in substantiating why the patient is to be considered temporarily incapacitated for this period.

5.Incapacitated - the patient is determined unemployable, unable to maintain any formal employment. The severity of this incapacity should be reflected and amplified in the “Comments” section.

If block 2, 3, 4 or 5 is completed, the “Comments” section must be completed in terms that are comprehensible to a person not familiar with medical terms. (i.e., use terms such as cancer, diabetes, epilepsy, heart disease, psychosis, etc.). Prescription drugs which are prescribed from the P.D.R. categories or their generic equivalent as health sustaining medication, in connection with the primary or secondary diagnosis, must be identified. The information requested for persons who have received in patient care in a hospital or psychiatric unit for persons with mental illness/emotional disturbance or a public or private intermediate care facility for persons with mental retardation (ICF/MR) should be completed when the patient’s record substantiates this information.

Sections IV. and V. Complete as indicated.

The medical provider’s name, address and date of the client’s last examination can be written, typed or stamped on the bottom of page 4. Signature of the physician or the physician or psychologist affiliated with a psychiatric clinic and date of signature is required.

PA586 8/07

SECTION I COMPLETED BYCAO

I HEREBY AUTHORIZE THE RELEASE OF MEDICAL/CLINICAL INFORMATION TO THE DEPARTMENT OF PUBLIC WELFARE AS NECESSARYTO DETERMINE MYELIGIBILITYFOR ASSISTANCE.

SIGNATURE OF PUBLIC ASSISTANCE APPLICANT/RECIPIENT

DATE

ARRANGE FOR AN APPOINTMENT WITH APHYSICIAN OR LICENSED PSYCHIATRIC CLINIC. MAILOR RETURN THE FORM TO THE COUNTYASSISTANCE OFFICE AS SOON AS POSSIBLE ASK THE CAO WORKER FOR HELPTO SCHEDULE AN APPOINTMENT IF NECESSARY.

SECTION II TO BE COMPLETED BYPHYSICIAN OR PSYCHOLOGIST

HISTORY(Complaints and history of present illness or dysfunction: (give date of onset))

DIAGNOSTIC STUDIES PREVIOUSLYPERFORMED: (Enter here the results of any special X-Ray, laboratory and other diagnostic studies relating to patient’s present illness or disability - Give Dates.)

RETURN TO:

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SECTION V CLINICALFINDINGS (TO BE COMPLETED BYPHYSICIAN)

THE INFORMATION IN THIS SECTION WILLBE USED BYTHE CAO TO MAKE AN ASSESSMENTOF YOUR PATIENT’S QUALIFICATION FOR (1) GENERALASSISTANCE OR (2) EXEMPTION FROM PUBLIC ASSISTANCE WORK REQUIREMENTS BECAUSE OF APHYSICAL OR MENTALCONDITION.

	Ab-	Not	DETAILED INFORMATION
Normal		Evalu-
	normal	ated

A.HEAD, NECK

B.EYES AND EARS (General)

C.NOSE, THROAT, MOUTH

D.BREASTS

E.PULMONARYDIAGNOSIS (if abnormal, please check () appropriate diagnosis and provide detailed information which includes physical findings).

BRONCHITIS		BRONCHIAS ASTHMA
BRONCHIECTASIS		EMPHYSEMA
PNEUMOCONIOSIS (Stage)		PULMONARYFIBROSIS
TUBERCULOSIS		TUMOR
OTHER

DETAILED INFORMATION SHOULD INCLUDE PERCUSSION, EFFECTOF

EXERCISE, AUSCULATION, ETC.

F.CARDIOVASCULAR DISEASE (if abnormal, please provide diagnosis in blank

space and include American Heart Association classification. Also check () appropriate signs and symptoms block(s) and provide detailed information).

DIAGNOSIS:

DYSPNEA:		ON EXERTION		ATREST
CHECK PAINS:				PERIPHERALEDEMA(Site & Degree)
LUNGS: (Rales, Emphysema, etc.)				CYANOSIS: (Lips, Nails)
HEART: ENLARGEMENT				PULSE RATE: _____ Before exercise
MURMURS: (Locateanddescribe)				_____ Afterexercise
PERIPHERALVESSELS: (Describe)				LIVER ENLARGEMENT: (Degree)
CARDIAC CLASSIFICATION (AHA)

G.HEMIC (Sickle Cell, Anemia,Clotting Disorders, Leukemia)

H.LYMPHATIC

I.MULTIPLEBODYSYSTEMDISORDERS(Lupus,MorbidObesity,etc.)

J.IMMUNE DISORDERS (AIDS, etc.)

K.NEOPLASTIC DISEASE (Cavier, etc.)

L.SPECIALSENSES & SPEECH DISORDERS

M.ABDOMEN(palpitableabnormalities,hernia,scars,digestivedisorders)

N.RECTUM (Hemorrhoids, Prostate, Other)

O.ENDOCRINE SYSTEM

P.G-U SYSTEM

Q.EXTREMITIES

R.ORTHOPEDIC DISORDERS (Identify type of disorder and indicate range of motion,

strength, ankylosis, muscle atrophy, etc.). If arthritis, specify type and check () site of involvement.

HIPS		KNEES		ANKLES
TOES		SHOULDERS		ELBOWS
WRISTS		FINGERS		SPINE

REMAINING FUNCTION: Describe patient’s ability to do the following:

WALK		STAND				KNEEL
STOOPOR BEND		LIFT				CARRY
IS ABRACE OR PROSTHESIS WORN?					YES			NO

TYPE? _______________________ FOR HOW LONG? _____________

HOW EFFECTIVE IS APPLIANCE?

S.SKIN

T.PELVIC (Vaginal)

U.NEUROLOGIC (If neurologic disease or abnormality is present, provide diagnosis and detailed information such as describe reflex changes, motor impairment, disturbance of gait, coordination, etc.)

IF EPILEPTIC, CHECK () TYPE:
	GENERALIZED TONIC-CLONIC		SIMPLE PARTIALS
	COMPLEX PARTIALS		ABSENCE SEIZURES

IFSEIZURESAREPRESENT,DESCRIBESEIZURESANDINDICATEFREQUENCY.

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SECTION V CLINICALFINDINGS (CONTINUED)

DETAILED INFORMATION

V. PSYCHIATRIC

DIAGNOSIS: (IFABNORMAL, INDICATE DIAGNOSIS)

MENTAL OR EMOTIONAL DISTURBANCE (Please check () appropriate abnormalities and provide detailed information.)

A. ABNORMALITIES OF BEHAVIOR AND APPEARANCE.

B. EVIDENCE OF POOR COMPREHENSION OR CONFUSION.

C. ABNORMALEMOTIONALREACTION.

D. ABNORMALTHOUGHTS OR IDEAS (Givedescriptivequote)

E. LEVELOF MENTALRETARDATION (Indicate IQ if known)

		NONE		MILD				MODERATE
		SEVERE		PROFOUND
DO YOU CONSIDER THIS PERSON CAPABLE OF MANAGING HIS/HER
OWN AFFAIRS?				YES		NO
IS THIS PERSON ORIENTED FOR TIME?								YES		NO

PLACE ______________________ OR PERSON _____________

IS MEMORYDEFECTPRESENTFOR RECENTEVENTS? YES NO

F. PSYCHOMOTOR

SUMMARYAND EVALUATION: What is your general impression of the patient’s attitude toward his/her condition?

Is further study or specialist examination advisable for completeness of diagnosis, prognosis or treatment?

If so, specify type and indicate specialist or institution of your choice.

I HEREBYCERTIFYTHAT THE INFORMATION ABOVE IS BASED ON AN EXAMINATION OF THE PATIENT ON ________________

AND THAT IT IS TRUE TO THE BEST OF MYKNOWLEDGE, INFORMATION AND BELIEF.	DATE

PHYSICIAN’S/PSYCHOLOGIST’S PRINTED NAME,ADDRESS & LICENSE NO. PHYSICIAN’S/PSYCHOLOGIST’S SIGNATURE

PREPAREDDATE

PHYSICIAN

PSYCHOLOGIST

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