Medical Evaluation Form
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1
2MEDICAL EVALUATION
ohiosearchkeydmr
Individuals Name:
Waiver:
I.
System Disorder
Name of Condition
Date of Onset
Circle One
a. Respiratory
Yes
No
b. Cardiovascular
Yes
No
c. Gastro-Intestinal
Yes
No
d. Genito – Urinary
Yes
No
e. Neurological
Yes
No
f. Other
Yes
No
II.
History of Seizures (Type)
Date of Onset
Simple Partial (Simple motor movements/no awareness loss)
Yes
No
Complex Partial (Loss of awareness)
Yes
No
Generalized – Absence (petit mal)
Yes
No
Generalized – Tonic-Clonic (grand mal)
Yes
No
Controlled with medication
Yes
No
Other:__________________
Seizure Frequency per month:
III.
Disability
Date of Onset
Mental Retardation
Yes
No
Autism
Yes
No
Cerebral Palsy
Yes
No
Mental Illness
Yes
No
Other: ________________________________
IV.
Sensory/Motor Limitation
Hearing
Yes
No
Vision
Yes
No
Ambulatory
Yes
No
Fine Motor Deficit
Yes
No
Major Motor Deficit
Yes
No
Communication
Yes
No
V.
Treatment Modality
Physical Therapy
Yes
No
Occupational Therapy
Yes
No
Speech Therapy
Yes
No
Special Diet Type: _________________________________
Other:
_________________________________
(IV, Tube Feed, O
, Catheter, etc.)
2
Special Equipment _________________________________
VI.
Medications: (Use reverse side of this sheet for additional medications)
Individual can self medicate:
Yes
No
Medication
Dose
Related Diagnosis or Condition
VII.
Physician Signature
_____________________
________________________
__________________
Physician Name (print)
Physician Signature
Date
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