Form G-250 (09-05)

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0038

MEDICAL ASSESSMENT

1 SECTION I- Instructions
Some items on this form will not apply to you and you will not need to answer them. Based on your
answer to a question, you may be told to skip to another item number, or even another section. Follow
the instructions that tell you to "Go to" another item. These are designed to save you time and help you
move through the application quickly, filling in only necessary information. If no "Go to" instructions are
given, answer the next item in order. Do not skip any items unless directed to do so. Enter " N A for not
affected or "UNK for unknown, as appropriate.
Please read the Privacy Act and Paperwork Reduction Notice on page 7.

Address
I

1 Telephone Number

-

SECTION 3 General Information
1

Enter the date you began treating the patient.

2

Enter the date of the last examination.

3

Enter the patient's weight and height.

Month

Day

Year

Month

Day

Year

Weight
Height

-

SECTION 4 Musculoskeletal System
4 A Enter an "X" in the appropriate box:

YES - Go to Section 5
NO - Go to Item 4B

Is the musculoskeletal system normal?
I

B

Describe the impairment. Attach a copy of any x-ray reports, MRI reports, CT scan reports, etc.

Enter an "X" in the appropriate box:
Is there a limitation of motion in the spine or
any joints?

YES - Check this box then go to ltem 5B
and enter either:
the range of motion or
an "N" for normal range of
motion
NO - Check this box then go to ltem 6
RRB Form G-250 (09-05) Destroy Prior Editions

5

B

Normal
Degrees

CERVICAL SPINE
Flexion

DORSOLUMBAR SPINE
Flexion

45
45

Extension

30

Right Lateral Flexion

45

Right Lateral Flexion

30

Left Lateral Flexion

45

Left Lateral Flexion

30

Right Rotation

60

Left Rotation

60
Right

Left

HIP

Right

Abduction

150

Abduction

40

Forward Elevation

150

Adduction

20

Internal Rotation

80

Flex~on

100

External Rotation

80

Extension

30

Internal Rotation

40

External Rotation

50

ELBOW
Flexion
Extension

150
0

KNEE

Supination

80

Flexion

Pronation

80

Extension

WRIST

150
0

ANKLE

Dorsi-Flexion

60

Dorsi-Flexion

20

Palmar-Flexion

70

Plantar-Flexion

40

Enter an "X" in the appropriate box:

7

Are there paraspinal muscle spasm present on
examination?
Describe muscle strength on a graded scale.

8

Describe any sensory or reflex abnormalities.

9

A

Describe, in detail, the patient's gait and station.

YES
NO

Actual
Degrees

90

Extension

SHOULDER

6

Normal
Degrees

Actual
Degrees

Left

9

B

Enter an "X" in the appropriate box:

YES - Go to ltem 9C
NO - Go to ltem 10

Does the patient walk with an assistive
device?

10

C

How far can the patient walk without using an assistive device?

A

Enter an "Xuin the appropriate box:
Are there any abnormalities in the patient's
hands or fingers?

B

YES - Go to ltem 10B
NO - Go to Section

Describe any restrictions in the patient's ability to perform gross and fine manipulations. For
example, can the patient pick up a pencil or turn a door knob, etc.? Quantify grip strength on a
graded scale.

-

SECTION 5 Cardiovascular System
11

A

Enter an "X" in the appropriate box:

YES - Go to Section 6
N O - G o t o Item 11B

Is the cardiovascular system normal?
11

B

12

Describe any signs of congestive heart failure.

Describe the impairment. Provide any signs of decompensation (edema, cyanosis), etc. Describe
any chest pains including character, location, radiation, frequency, duration, precipitating factors,
relieving factors, and associated symptoms. Attach a copy of any EKG tracings, x-ray reports,
etc.

,

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RRB Form G-250 (09-05)

13

Describe any rhythm disturbances.

14

Describe any evidence of arterial or venous insufficiency (e.g., intermittent claudication, pulse deficits,
brawny edema, etc.).

-

SECTION 6 Respiratory System
15 A Enter an " X in the appropriate box:

YES - Go to Section 7
N O - G o t o Item 15B

Is the respiratory system normal?
B

Provide detailed objective findings. Attach a copy of any pulmonary function test (including
tracings), x-ray reports, or sputum culture results.

-

SECTION 7 Neurological System
16 A Enter an " X in the appropriate box:

YES - Go to ltem 16B
NO - Go to Section 8

Is there a neurological impairment?
B

17

Describe, in deta~l,any abnormal neurological findings.

Describe the character, the frequency of attack and the response to medication of any convulsive or
seizure disorder.

-

SECTION 8 VisionlHearinglSpeech
RRB Form G-250 (09-05)

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Enter an "X" in the appropriate box:

A

18

YES - Go to Section 9
- Go to
188

Is the patient's vision, hearing, and speech
normal?
I

B

If there is a vision impairment, provide information about any deficiency in central visual acuity
(before and after correction), peripheral visual fields, or other function. Attach a copy of the

C

If there is a hearing impairment, describe the limitations in the patient's hearing. Attach a copy
of any audiometric charts.

D

If there is a speech impairment, describe any abnormalities in the patient's speech.

-

SECTION 9 Mental Functions
19

Enter an "X" in the appropriate box:

A

Does the patient have a severe mental
impairment?

Describe the impairment, including emotional reactions, conduct disturbances, orientation, insight,
judgment, hallucinations, delusions, memory for recent and remote events, and evidence of
mental deterioration. Note any changes in the patient's normal activities of daily living.. List
medication(s) and response.

B

I

YES - Go to Item 19B
NO - Go to Section 10

I

-

SECTION 10 Other Systems and Impairments

I

B

Are there any impairments in other systems?
NO - Go to Section 11
Describe the impairment and provide any relevant findings.

-

SECTION II Exertional Restrictions
21

A
B

Enter an " X in the appropriate box:

YES - Go to ltem 21B
NO - Go to Section 12
Are there any exertional restrictions?
Describe, in detail, any type of exertional restriction (e.g., limitations on lifting, standing, walking,
sitting, stooping, crouching, climbing, etc.)

-

SECTION 12 Environmental Restrictions
22

A

Enter an "X" in the appropriate box:

B

Are there any environmental restrictions?
Describe any environmental restrictions (e.g., can the patient work around heights, around
machinery, walk on uneven terrain, be exposed to dust, fumes, noise, vibration, temperature
extremes etc.?).

-

SECTION 13 Signature
SIGNATURE

RRB Form G-250 (09-05)

YES - Go to ltem 22B
NO - Go to Section 13

(This reporf must be signed. A stamped signature is not acceptable.)
AREA CODE

DATE

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TELEPHONE NUMBER

PRINTED NAME

TITLE
I

ADDRESS

PLEASE REMEMBER TO INCLUDE ALL OFFICE NOTES WHEN RETURNING THIS FORM.
PRIVACY ACT AND PAPERWORK REDUCTION NOTICE
The information requested on this form is authorized by Section 7(b)(6) of the Railroad Retirement Act.
While you are not required to respond, your cooperation is needed to provide information necessary to
complete processing for the claimant named and to determine the claimant's entitlement to disability benefits
under the Railroad Retirement Act.
We estimate this form takes an average of 30 minutes per response to complete, including time for
reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Federal agencies may not conduct or sponsor, and
respondents are not required to respond to, a collection of information unless it displays a valid OVIB
nuniber. If you wish, send comments regarding the accuracy of our estimate or any other aspect of this
form, including suggestions for reducing completion time, to Chief of Information Resources Management,
Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611-2092.

RRB Form G-250 (09-05)