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pdfUnited States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0038
MEDICAL ASSESSMENT
Proposed
SECTION 1 - 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 this Medical Assessment 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.
Please read the Important Notices on page 7.
SECTION 2 - Patient Identification
Railroad Retirement Claim Number
Social Security Number
Name
Address
,
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:
Is the musculoskeletal system normal?
5
YES - Go to Section 5 A
NO - Go to Item 4B
B
Describe the impairment. Attach a copy of any x-ray reports, MRI reports, CT scan reports, etc.
A
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 Item 5B
and enter either:
the range of motion or
an "N" for normal range of
motion
NO - Check this box then go to Item 6
RRB Form G-250 (08-15) Destroy Prior Editions
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5
Normal
Degrees
B
CERVICAL SPINE
Flexion
Actual
Degrees
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
Right
150
Abduction
40
Forward Elevation
150
Adduction
20
Internal Rotation
80
Flexion
External Rotation
80
Extension
30
Internal Rotation
40
External Rotation
50
Flexion
150
Left
100
KNEE
Extension
0
Supination
80
Flexion
Pronation
80
Extension
WRIST
7
HIP
Abduction
ELBOW
Actual
Degrees
90
Extension
SHOULDER
6
Normal
Degrees
150
0
ANKLE
Dorsi-Flexion
60
Dorsi-Flexion
20
Palmar-Flexion
70
Plantar-Flexion
40
Enter an "X" in the appropriate box:
Are there paraspinal muscle spasmspresent on
examination?
Describe muscle strength on a graded scale.
YES
NO
(0 to 5/5).
Lower Extremity (Name left or right joint or muscle group and grade):
Upper Extremity (Name left or right joint or muscle group and grade):
8
Describe any sensory or reflex abnormalities.
reflexes on a graded scale (0 to 4+) and describe any sensory abnormalities.
Lower Extremity (Name left or right joint or muscle group and grade):
Upper Extremity (Name left or right joint or muscle group and grade):
9
A
Describe, in detail, the patient's gait and station.
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RRB Form G-250 (08-15)
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9
B
Enter an "X" in the appropriate box:
YES - Go to Item 9C
NO - Go to Item 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 Item 10B
NO - Go to Section 5
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
NO - Go to Item 11B
Is the cardiovascular system normal?
11
B
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.
12
Describe any signs of congestive heart failure.
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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
NO - Go to 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 Item 16B
NO - Go to Section 8
Is there a neurological impairment?
B
17
Describe, in detail, any abnormal neurological findings.
Describe the character, the frequency of attack and the response to medication of any convulsive or
seizure disorder.
SECTION 8 - Vision/Hearing/Speech
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RRB Form G-250 (08-15)
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18
A
Enter an "X" in the appropriate box:
Is the patient's vision, hearing, and speech
normal?
YES - Go to Section 9
NO - Go to Item 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 Item 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.
SECTION 10 - Other Systems and Impairments
20
A
Enter an "X" in the appropriate box:
YES - Go to Item 20B
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B
Are there any impairments in other systems?
NO - Go to Section 11
Describe the impairment and provide any relevant findings.
SECTION 11 - Exertional Restrictions
21
A
B
Enter an "X" in the appropriate box:
YES - Go to Item 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
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.?).
SECTION 13 - Certification
With the understanding that section 13 of the Railroad Retirement Act (45 U.S.C. 231I) provides that anyone
who makes false or fraudulent statements or claims for the purpose of causing an award or payment under
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RRB Form G-250 (08-15)
the Railroad Retirement Act is subject to a fine of up to $10,000, or imprisonment of up to one year, or both, I
certify that the information I have furnished is correct to the best of my knowledge.
Signature (This report must be signed.
A stamped signature is not acceptable)
Date
Printed Name and Title
National Provider Identifier
Address and Daytime Telephone Number
Area Code
Telephone Number
Please return this form along with copies of your office records to:
RAILROAD RETIREMENT BOARD
NAME
OFFICE OF OFFICE
PROGRAMS
/POLICY & SYSTEMS
NORTH RUSH STREET
844 ADDRESS
ZIP
CCITY,STATE,
HICAGO, IL 60611-1275
IMPORTANT NOTICES
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
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 OMB 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 60611-1275.
Associate Chief Information Officer for Policy and Compliance
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICES
The Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) requires the Railroad Retirement
Board to advise you that information you have provided may be used, without your consent, in automated
matching programs. These matching programs are a computer comparison of RRB records with records kept
by other Federal, state, or local governmental agencies. Information from the programs can be used 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.
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RRB Form G-250 (08-15)
File Type | application/pdf |
File Title | Microsoft Word - G-250 Current.docx |
Author | HILLDES |
File Modified | 2019-07-31 |
File Created | 2019-07-02 |