Category II - MER Paper Submissions (subset of "MER Samples") category

CLAIMANT:
DDS CASE NUMBER:
DEA:

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248
ATE000

DIABETES QUESTIONNAIRE FOR TREATING SOURCE
1. Please include treatment notes, and lab tests
from
to
2. Diagnosis
3. Date of onset of symptoms.
4. Height
Weight

Date

5. Date and results of the latest blood sugar evaluation and glycohemoglobin (HbA1C).

6. If acidosis has occurred on the average of at least once every two months, please
indicate blood chemical test (PH or PCO2 or bicarbonate levels) and the dates
performed.

7. If the patient has sustained an amputation due to diabetic necrosis or peripheral
vascular disease, please describe and indicate the date of the amputation.

8. If present, please describe any visual abnormalities due to diabetes.

9. Is there any evidence of neuropathy? If so, please describe. Is an assistive device
medically required for ambulation? When was it prescribed?
10. Is the Diabetes under satisfactory control?  Yes  No
11. Please describe compliance and response to treatment.

12. Please indicate any other observable conditions or pertinent clinical findings that
might affect the patient's functional abilities.
13. Date first seen:

Date last seen:

Frequency of visits:

Thank you for your cooperation.
Physicians Signature
Date
Phone Number

MSC 223 (07/10)
Page 1 of 1

Print or type name
Best time to call

CLAIMANT:
DDS CASE NUMBER:
DEA:

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248
ATE000

Treating Physician
General Medical Evaluation
Directions: Please provide a current assessment using objective findings. This
information is necessary to evaluate this patient’s disability claim. Please indicate if
normal. If abnormal, please list specific findings. (Please use reverse side if
additional space is needed.)
Date of Exam:

Frequency of Visits:

General Appearance
1. Height:

Weight:

Blood Pressure:

2. Best Corrected:

OD _____________

OS ______________

3. If uncorrected give:

OD _____________

OS ______________

Eyes

4. Describe any severe disease/visual defect (including visual fields):

Ears
5. Can your patient hear normal conversation? Yes  No 
If no, please explain.

Respiratory System
6. Lungs:
7. Details of dyspnea, if any:

Cardiovascular
8. Chest pain of cardiac origin? Yes  No 
If yes, please describe, including symptoms:
9. Peripheral vascular pulses:

MSC 234 (07/10)
Page 1 of 2

CLAIMANT:
DDS CASE NUMBER:
DEA:

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248
ATE000

Abdominal
10. Abdomen/pelvis findings:

11. Organomegaly? Yes  No 
If yes, please describe.

Musculoskeletal
12. Please provide range of motion (ROM) and describe affected joint(s) and/or spine.

Neurological System
13. Please describe the following:
a.
b.
c.
d.
e.

Gait:
Reflexes:
Sensory:
Motor:
Atrophy? Yes  No 
If yes, please describe.

f. Does your patient have seizures? Yes  No 
If yes, please describe (including frequency).

Comments:
14. Please provide comments below on other conditions your patient has which are not
already described above.

Name of Physician (printed)

Physician Signature

Date ________________ Telephone # and extension: (_______)

MSC 234 (07/10)
Page 2 of 2

CLAIMANT:
DDS CASE NUMBER:
DEA:

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248
ATE000

TREATING SOURCE SUMMARY OF VISION FINDINGS
1. DIAGNOSIS:

OD
OS

2. DISTANCE VISUAL ACUITY:
Without correction (leave blank if not checked): OD

OS

Date

With correction (leave blank if not tested)

OS

Date

OD

Most recent manifest refraction: Date __________ Check here if unknown 
OD _____________________ = 20/_____________
OS _____________________ = 20/_____________
3. Describe any pathological findings:
4. What surgery has been performed? None 
OD

Date

OS

Date

5. Has formal Visual Field testing been done? Check all that apply.
 No.  No significant visual field deficit expected.
 Yes. Was this a reliable field consistent with ocular pathology?  Yes  No
Date of test _________________
Please include the visual field printouts with this report.
6. Indicate earliest date:
Best corrected VA in the better eye was limited to 20/200 or worse:
N/A ____ Date: _________
Residual visual field in the better eye was 20 degrees or less in widest diameter:
N/A ____ Date: _________
Please include supporting clinic notes or VF test results for that date.
7. Please comment on treatment plan and prognosis over the next 12 months:

Signature of:

Physician 

MD/OD Name (please print)

MSC 201 (07/10)
Page 1 of 1

Optometrist 
(
)
Phone No.

Date
Best time to contact you

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. The OMB control number for this
collection is 0960-0555. We estimate that it will take between 5 to 30 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

PRIVACY ACT STATEMENT
Collection and Use of Information by the Social Security Administration
The Privacy Act of 1974 (5 U.S.C. § 552a) requires us to provide certain facts to each person from whom we
request and collect information in order to administer our programs. These facts include:
• the statutory authority for the request;
• why we need the information;
• whether it is voluntary or mandatory for you to give us the information and the effects, if any, of not
giving us the information; and
• the uses we may make of the information you give us.
The following sections explain our collection, use, and disclosure of the information you give us. If you have
any questions about your rights and responsibilities under the Privacy Act, you may contact any local Social
Security office.
Our authority to collect information
Our specific authority to collect information is found
in sections 205(a), 702, 1631(e)(1)(A) and (B),
1631(f), 1872, and 1875 of the Social Security Act
(the Act), as amended. Additional authority is in
part B of the Federal Coal Mine Health and Safety
Act of 1969.

information to another agency or person without
your written consent. We make these disclosures
for the following reasons:
•
•
•

Why we need the information
We collect information from you in order to
administer our programs. Specifically, the
information we request enables us to:
•
•
•
•
•

assign Social Security numbers;
establish and maintain earnings records;
determine entitlement of applicants and
their families to insurance coverage and or
benefit payments;
issue payments in the right amount for the
right months to people entitled to them; and
conduct program-oriented research in areas
of income distribution and maintenance.

Is providing information voluntary or
mandatory?
It is not mandatory for you to give us the
information we request except in certain instances
explained below. It is usually to your advantage to
comply with our request for information. Failure to
do so, however, could prevent an accurate and
timely decision on a claim you file or result in the
loss of some benefit or service.
Our use(s) of the information you give us
We use the information you give us to administer
our programs. Sometimes we must disclose the

•

to enable a third party or agency to assist us
in establishing your right to benefits or
coverage;
to comply with Federal laws;
to make eligibility determinations in similar
Federal, State, and local health and income
maintenance programs;
to facilitate statistical research, audit, or
investigative activities necessary to assure
the integrity of our programs.

We may also use the information you give us when
we match records by computer. Computer
matching programs compare our records with those
of other Federal, State, or local government
agencies. We use the information from these
matching programs to establish or verify a person’s
eligibility for Federally-funded or administered
benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses of the information
you give us is available in our Privacy Act Systems
of Records Notices. For example, the application
for benefits and supporting documentation of the
factors of entitlement and continuing eligibility is
contained in our Claims Folder System (60-0089);
medical information, doctors’ reports, and State
disability determinations related to a disability claim
is contained in our National Disability Determination
Services File System (60-0044). Additional
information regarding this form, routine uses of
information, and other Social Security programs is
available from our Internet website at
www.socialsecurity.gov or at your local Social
Security office.
Form SSA-5000 (05-2011)