MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION MEDICAL REPORT INCLUDING PHYSICIAN’S CERTIFICATION/DISABILITY EVALUATION
INDIVIDUAL NAME (FIRST) (MIDDLE) (LAST) INDIVUDIAL DCN DATE OF BIRTH COUNTY ELIGIBILITY SPECIALIST FAMIS USER ID LOAD DATE OF APP/REAPP/REVIEW DATE SUBMITTED TO MRT
TO THE EXAMINING PHYSICIAN :	Physician’s Name:	Specialty:
The above named person is applying for or is a member of a household which is applying for public assistance based on disability. Eligibility for assistance will be based, in part, on the medical information that you supply on this form. Therefore, please complete the entire form as thoroughly and accurately as possible. We need to know if this person has a mental or physical disability which makes him/her unable to function at his/her normal occupation or other suitable employment. After an examination has been completed and/or the medical information entered on the form, your opinion is needed about the person’s mental and/or physical condition with regard to employability. NOTE: The Family Support Division will not assume responsibility for payment of inpatient costs unless prior written authorization is given by the County Manager of the Family Support Division office that initiated this form. If you feel that hospitalization is required before you can make a decision regarding employability, indicate this on the form and return it to the Family Support Division County Office.
TO BE COMPLETED BY THE EXAMINING PHYSICIAN
ARE YOU NOW OR HAVE YOU TREATED THIS PATIENT IN THE PAST YEAR? YES NO IF YES, DATE
BRIEF CLINICAL HISTORY (CHIEF COMPLAINTS)
HAS PATIENT BEEN HOSPITALIZED WITHIN THE PAST YEAR? NO YES IF YES, ENTER NAME OF HOSPITAL ►	HOSPITAL
COMPLETE FOR EACH PERSON	BLOOD PRESSURE	HGB OR HCT IF INDICATED	URINALYSIS
WEIGHT	HEIGHT	SYSTOLIC	DIASTOLIC	HGB	HCT	SUGAR	ALBUMEN
EYES	VISION CORRECTED BY GLASSES TO	EARS HEARING (ORDINARY CONVERSATION
RIGHT	LEFT	RIGHT	LEFT	RIGHT(20 FT.)	LEFT (20 FT.)
NOSE, THROAT, MOUTH, NECK (ABNORMALITIES)
CARDIOVASCULAR SYSTEM
CARDIAC ENLARGEMENT? YES NO	DEGREE	MURMURS	RHYTHM
EVIDENCE OF CARDIAC DECOMPENSATION YES NO BASILAR RALES YES NO LIVER ENLARGEMENT YES NO PERIPHERAL EDEMA YES NO IF YES, PLEASE EXPLAIN.
ANGINA PECTORIS? YES NO DESCRIBE PAIN AND AMOUNT OF EXERTION REQUIRED TO PRODUCE IT.
PULSE RATE	DYSPNEA	CYANOSIS	EDEMA	TYPE OF HEART DISEASE	FUNCTIONAL CLASSIFICATION
PERIPHERAL ARTERIAL DISEASE? YES NO IF YES, EXPLAIN
ABSENT PULSATION? YES NO IF YES, EXPLAIN
VARICOSITIES? YES NO IF YES, EXPLAIN
PULMONARY FUNCTION	RIGHT	LEFT

MO 886-0731 (0306) E 04/2011 PERMANENT IM-60A (0306)

NERVOUS SYSTEM
PARALYSIS, SPEECH, GAIT, REFLEXES: PUPILLARY, KNEE, BABINSKI, ROMBERG
EVIDENCE OF PSYCHOSIS NEUROSIS MENTAL DEFICIENCY	DESCRIBE
SEIZURES NO YES IF YES, LIST ►	TYPE	FREQUENCY OF ATTACKS WITH MEDICATION
NEOPLASMS
SITE	BENIGN	MALIGNANT	METASTASES
BONES, JOINTS, AND EXTREMITIES
DESCRIBE DISEASE OR INJURY AND STATE LIMITATION OF MOTION, SUCH AS ABILITY TO WALK, STAND, BEND, STOOP, GRASP, ETC.
ABDOMEN
SCARS	TENDERNESS	PALPABLY ENLARGED ORGANS	HERNIA
DESCRIBE ITEMS CHECKED
GENITO-URINARY
URETHRAL DISCHARGE	HYDROCELE	EPIDIDYMITIS	PROSTATE	ABNORMAL TESTICAL
DESCRIBE ITEMS CHECKED
GYNECOLOGICAL
PROLAPSE	CYSTOCELE	RECTOCELE	CERVIX	ADNEXA	PREGNANT	EXPECTED DUE DATE
DESCRIBE ITEMS CHECKED
ANO-RECTAL
HEMORRHOIDS	PROLAPSE	FISSURES	FISTULA
DESCRIBE ITEMS CHECKED
OTHER LABORATORY FINDINGS (ATTACH WRITTEN REPORT OF X-RAYS, EKG, OR OTHER LABORATORY FINDINGS)
DIAGNOSIS (physical) : Diagnosis and GAF (Global Assessment of Functioning): (mental health)
PRIMARY
SECONDARY
KNOWN MEDICATIONS
SUMMARIZE FINDINGS WITH EMPHASIS ON FUCTIONAL CAPACITY
IS FURTHER DIAGNOSTIC EXAMINATION INDICATED? YES NO	TYPE
DETERMINATION OF INCAPACITY: In my opinion this individual ( does does not have) a mental and/or physical disability which prevents him/her from engaging in that employment or gainful activity for which his/her age, training, experience or education will fit him/her. When evaluating a child, the physical or mental impairment has to compare in severity to an impairment that would make an adult disabled and evidence of marked restriction in daily age appropriate activities must exist.
DURATION OF INCAPACITY: In my opinion, the expected duration of disability/incapacity will be: 1 month 3-5 months 13 or more months 2 months 6-12 months Permanent.
THE ABOVE FINDINGS AND STATEMENTS ARE BASED ON MY EXAMINATION AND/OR RECORDS.
SIGNATURE OF PHYSICIAN (Please print physician’s name beneath signature)	DATE
MO 886-0731 (0306)