Form 21-2545 Report of Medical Eamination for Disbility Evaluation

OMB Approved No. 2900-0052
Respondent Burden: 15 minutes

REPORT OF MEDICAL EXAMINATION
FOR DISABILITY EVALUATION

1A. FILE NO.

1B. VETERAN'S SOCIAL SECURITY NO.

C/CSS2. INSURANCE FILE NO. (V,H,K, etc., if pertinent)

Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38,
Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the
collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA
benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education,
and Vocational Rehabilitation and Employment Records - VA, and published in the Federal Register. Your obligation to respond is required to obtain or retain benefits.
VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN
account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to
provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested
information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701).
Information submitted is subject to verification through computer matching programs with other agencies.
Respondent Burden: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a
collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.
Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
INSTRUCTIONS TO THE VETERAN: Please complete all unshaded items on Page 1 of this form. Bring this form with you when reporting for the examination.
5. DATE OF EXAMINATION
4. PURPOSE OF EXAMINATION
3. FIRST, MIDDLE, LAST NAME OF VETERAN (Type or print)
6. HOME ADDRESS (Street or RFD Number, City, State and ZIP Code)

7. PLACE OF EXAMINATION

8. AGE OF VETERAN

SECTION A - OCCUPATIONAL HISTORY SINCE LATEST DISCHARGE FROM MILITARY SERVICE OR LATEST VA EXAMINATION
9. NAME AND ADDRESS OF EMPLOYER

(If unemployed enter "None")

10. TYPE OF WORK

11. MONTHLY
WAGES

12. DATES OF EMPLOYMENT
FROM

TO

13. TIME LOST
IN PAST 12
MONTHS

14. REASON FOR TIME LOST (If any)

SECTION B - MEDICAL HISTORY SINCE LATEST VA EXAMINATION AS RELATED BY PERSON EXAMINED

15. NARRATIVE HISTORY (Include manner and date of origin)

NAME AND ADDRESS OF DOCTOR OR HOSPITAL

CONDITION TREATED

FROM

TO

16A.

16B.

16C.
17. PRESENT COMPLAINT (Symptoms only, not diagnosis)

I HEREBY CERTIFY that the entries under Occupational and Medical History are complete and correct to the best of my knowledge.
18. DATE SIGNED
19. SIGNATURE OF PERSON EXAMINED (Do Not Print)

PENALTY - The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
AUG 2011

21-2545

EXISTING STOCKS OF VA FORM 21-2545, DEC 2004,
WILL BE USED.

PAGE 1 OF 4 PAGES

SECTION C - EXAMINATION (Examinee must be stripped)
INSTRUCTIONS TO THE EXAMINING PHYSICIAN: This report must be completely executed. Describe the results of a general examination of every system and
body parts including but not restricted to the systems and body parts involved in the history and present complaints. Wherever indicated specialists' examinations. Xrays, laboratory examinations, etc., should be recommended. If additional space is needed, comments may be continued in Item 44, "Remarks" or on separate sheets
attached to this form.
20. HEIGHT

21. WEIGHT

22. MAX. WT. PAST YEAR

25. CARRIAGE

26. POSTURE

27. GAIT

23. BUILD AND STATE OF NUTRITION

24. TEMPERATURE
DEGREES

lbs.
28. RIGHT-OR-LEFT-HANDED HOW DETERMINED

AM
AT

29. SKIN-INCLUDING APPENDAGES (Describe type, area, and extent of lesions. Report injuries, including burns, under Item 4)

PM

30. LYMPHATIC AND HEMIC SYSTEMS (Describe local or generalized adenopathy, enlargement, tenderness, suppuration, blocking of lymphatic circulation, etc.)

31. HEAD, FACE AND NECK

32. NOSE, SINUSES, MOUTH, AND THROAT (Include gross denial findings)

33A. EARS (Describe canals, drums, perforations, discharge)

33B. HEARING LOSS NOTED
YES
NO

34A. EYES (Describe external eye, pupil reaction, movements and field of vision)

34B. DISTANT VISION
R20/

CORRECTED TO 20/

L20/

CORRECTED TO 20/

35A. CARDIOVASCULAR SYSTEM (Describe thrust, size, rhythm, sounds, and condition of peripheral vessels)

35B. PULSE

35C. BLOOD PRESSURE

SITTING

S

D

RECUMBENT

S

D

STANDING

S

D

SITTING AFTER EXERCISE

S

D

2 MIN. AFTER EXERCISE

S

D

35D. RESPIRATION

36A. VARICOSE VEINS (Describe location, size, extent, ulcers, scars, and competency of deep circulation)

35E. IF NOT EXERCISED, GIVE REASON

36B. ARE ELASTIC STOCKINGS
NECESSARY?
YES

NO

36C. IS OPERATION RECOMMENDED?
YES
VA FORM 21-2545, AUG 2011

NO
PAGE 2 OF 4 PAGES

Attach Continuation Sheets, Specialists' Reports, Laboratory Reports, etc., in this space.
37A. RESPIRATORY SYSTEM (Describe cough, expectoration, mobility, palpation, percussion, and auscultation and specify area)

37B. SHAPE OF CHEST

37C. EXPIRATION
INCHES
37D. INSPIRATION
INCHES
38. DIGESTIVE SYSTEM (Describe findings on inspection and palpation, enlargements, masses, tenderness, rigidity, hemorrhoids (internal or external)

39. HERNIA (Describe type, location, size, whether complete, reducible, recurrent, retained by truss, and whether operable)

40. GENITO-URINARY SYSTEM (Describe kidneys, bladder, prostate, seminal vesicles, testes, cord, penis, and appendages; evidence of past or present venereal

disease; in females report pelvic exam, if indicated)

41. MUSCULO-SKELETAL SYSTEM
(A-DISEASES and INJURIES, include
effect of gunshot wounds and other
injuries on skin and underlying
structures.
B-SCARS, describe location,
measurements, depression, type of
tissue loss, adherence, disfigurement,
and tenderness.
C-FUNCTIONAL EFFECTS,
describe location, swelling, atrophy,
tenderness, degree of limitation of
flexion and extension, angle of fixation,
fracture, disease, fibrous or bony
residual, and specify mechanical aid
used and benefit.
D-FEET, describe objective evidence
of pain at rest and on manipulation,
rigidity, spasm, circulatory disturbance,
swelling, callus, strength, mobility
of ankles, feet, toes, and limitation
in degrees and indicate whether
right or left, acquired or congenital.
E-BURNS, degree and area in
square inches.)

42. ENDOCRINE SYSTEM (Describe disease of thyroid, pituitary, adrenals, pancreas, gonads, etc.)

VA FORM 21-2545, AUG 2011

PAGE 3 OF 4 PAGES

43. NERVOUS SYSTEM
(A-NEUROLOGICAL, describe motor
status, coordination, reflexes, sensory
status, equilibrium, and give exact
location.
B-PSYCHIATRIC and PERSONALITY,
describe behavior, comprehension,
coherence of response, emotional
reaction, orientation, memory, signs
of tension and status as to social
and industrial capacity.)

44. REMARKS (Cite the item number(s) continued in this space)

45A. LABORATORY TESTS, X-RAYS, BMR, EKG, ETC.

45B. DATE MADE

45C. URINALYSIS
SPECIFIC GRAVITY

ALBUMIN

SUGAR

MICROSCOPIC

45D. OTHER TESTS RECOMMENDED, ETC.
46. DIAGNOSIS

47A. IS EXAMINEE BEDRIDDEN?

47B. IS HOSPITALIZATION NEEDED?

47C. WILL EXAMINEE ACCEPT HOSPITALIZATION?

48A. IS EXAMINEE ABLE TO TRAVEL?

48B. ALONE?

48C. WITH ATTENDANT?

49. SPECIALISTS EXAMINATIONS RECOMMENDED

50. SIGNATURE OF PHYSICIAN

NAME AND SPECIALTY (Type or print)

DATE SIGNED

51. SIGNATURE OF PHYSICIAN

NAME AND SPECIALTY (Type or print)

DATE SIGNED

52. SIGNATURE OF PHYSICIAN

NAME AND SPECIALTY (Type or print)

DATE SIGNED

53. ATTACHMENTS MADE A PART OF THIS EXAMINATION (List by number or describe)

VA FORM 21-2545, AUG 2011

PAGE 4 OF 4 PAGES