Download:
pdf |
pdfUnited States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0038
MEDICAL ASSESSMENT
I
SECTION I - Instructions
I
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 "NA" for not
affected or "UNK for unknown, as appropriate.
1
Please read the Privacy Act and Paperwork Reduction Notice on .page
- 7.
SECTION 2 - Patient Identification
RRB Claim Number
Name
I
Address
Telephone Number
1
i
SECTION 3 - General Information
1
2
Enter the date you began treating the patient.
Enter the date of the last examination.
rT
3
/TION
Month
Day
I
I
Month
Day
Year
I
I
I
1
Year
Weight
Enter the patient's weight and height.
Height
.
4 - Musculoskeletal Svstem
Enter an "X" in the appropriate box:
Is the musculoskeletal system normal?
I
YES - Go to Section 5
NO - Go to Item 4B
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 ttfen go to ltem 6
RRB Form G-250 (09-05) Destroy Prior Editions
1 5
Is1
I
I
Normal
Degrees
CERVICAL SPINE
Flexion
Right Lateral Flexion
Left Lateral Flexion
Right Rotation
1
1
1
External Rotation
ELBOW
Flexion
Extension
1
1
45
45
60
I
I
Left
I
I
Actual
Degrees
90
30
Right Lateral Flexion
1
30
(
Left Lateral Flexion
(
30
I
I
1
1
1
1
I
1
150
80
80
150
1
1
1
I
1
I
1
I
I
I
0
80
I
I
I
I
I
Adduction
Flexion
Extension
Internal Rotation
External Rotation
KNEE
I
I
Extension
1
1
1
I
20
100
30
1
1
1
I
I
1
I
1
I
1
I
I
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.
Dorsi-Flexion
Plantar-Flexion
YES
NO
I
40
1
I
50
I
150
I
0
ANKLE
60
Left
40
Flexion
80
I
Right
Abduction
Palmar-Flexion
70
Enter an "X" in the appropriate box:
RRB Form G-250 (09-05)
Normal
Degrees
HIP
150
WRIST
Dorsi-Flexion
I
Extension
Right
Supination
Pronation
I
60
Abduction
Internal Rotation
I
DORSOLUMBAR SPINE
Flexion
SHOULDER
Forward Elevation
Actual
Degrees
45
Left Rotation
1
I
1
I
45
Extension
I
I
I
20
40
1
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 "X" in 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 l t e m 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.
-3-
RRB Form G-250 (09-05)
Describe any rhythm disturbances.
Describe any evidence of arterial or venous insufficiency (e.g., intermittent claudication, pulse deficits,
brawny edema, etc.).
-
N 6 Respiratory System
I
Enter an " X in the appropriate box:
YES - Go to Section 7
N O - Go to Item 15B
I
Is the respiratory system normal?
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 "Xuin the appropriate box:
YES - Go to Item 16B
NO - Go to Section 8
Is there a neurological impairment?
I
Describe, in detail, any abnormal neurological findings.
I
Describe the character, the frequency of attack and the response to medication of any convulsive or
seizure disorder.
RRB Form G-250 (09-05)
-4-
SECTION 8 - VisionIHearinglSpeech
18 A Enter an "X" in the appropriate box:
Is the patient's vision, hearing, and speech
normal?
YES - Go to Section 9
N O - Goto ltem 18B
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
visual field charts.
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 A Enter an "X" in the appropriate box:
YES - Go to ltem 19B
NO - Go to Section 10
Does the patient have a severe mental
impairment?
B
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.
-5-
RRB Form G-250 (09-05)
SECTION 10 - Other Systems and Impairments
20
A
B
Enter an " X in the appropriate box:
YES - Go to Item 20B
NO - Go to Section 11
Are there any impairments in other systems?
Describe the impairment and provide any relevant findings.
-
SECTION II Exertional Restrictions
21
A
Enter an " X in the appropriate box:
B
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.)
YES - Go to Item 21 B
NO - Go to Section 12
-
SECTION 12 Environmental Restrictions
22
A
B
Enter an " X in the appropriate box:
YES - Go to Item 22B
NO - Go to Section 13
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.?).
RRB Form G-250 (09-05)
-6-
SECTION 13 - Signature
(This report must be signed. A stamped signature is not acceptable.)
SIGNATURE
DATE
PRINTED NAME
TITLE
AREA CODE
TELEPHONE NUMBER
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 OlVlB
number. 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 6061 1-2092.
-7-
RRB Form G-250 (09-05)
| File Type | application/pdf |
| File Modified | 2008-07-21 |
| File Created | 2008-07-21 |