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DMA -5006 (Rev. 10/91)

STATE OF NORTH CAROLINA

(DSS - 1653)

DEPARTMENT OF HUMAN RESOURCES

REPORT OF MEDICAL EXAMINATION REQUESTED BY

________________________ COUNTY DEPARTMENT OF SOCIAL SERVICES

Part I. (To be filled in by county DSS)

Case No. ________________________________________

Name of patient ________________________________________ Dist No. __________________

Address

________________________________________________________________________

Age or birthdate _____________________________ / SSN ______________________________

______________________

__________

Date

Director of Social Services

Part II.

(For Applicant, Recipient, Personal Representative or Guardian)

I hereby authorize any physician, hospital, or clinic who has treated or examined me to give the county

Department of Social Services and the Disability Determination Section, Department of Human

Resources, information about my present or past condition of health.

_______________________

__________

Date

Signature of Applicant, Recipient, Personal

Representative or Guardian

Part III. (Medical Report) Note to physicians/psychologists: Please complete this form giving sufficient

details to enable a reviewing physician to make an independent determination as to the severity and

duration of the impairments. This form is provided for your convenience. The substitution of a narrative

report is acceptable. In addition, copies of office notes, hospital discharge summaries and especially,

reports of laboratory studies, x-rays and other objective studies for at least the previous 12 months are

needed. A signed consent for release of information is attached.

A. Complaint (In patient's own words) ________________________________________________

_____________________________________________________________________________

Date of Onset ______________________ Date of First Examined _______________________

Frequency of Visits __________________ Date of Most Recent Examination _______________

History ______________________________________________________________________

B. Findings on Examination:

General Appearance _______________ Posture ______________ Gait _________________

Height ___________

Weight ___________

Cardio-Vascular System:

(1) Blood Pressure

___(Systolic)_____

Pulse Rate __________ Rhythm ___________

(Diastolic)

(2) Heart: Size ___________ Sounds ___________

(3) Edema _____________

(4) Dyspnea ___________

( ) At rest

( ) On slight exertion

( ) On moderate exertion

(5) Angina _____________

( ) At rest

( ) On slight exertion

( ) On moderate exertion

(6) Functional capacity (American Heart Assn.)

Class I _____ II _____ III _____ IV _____

(7) Report of ECG: ______________________________________ Date ________________

(8) Degree of Arteriosclerosis, if present: ___________________________________________

Figure 3

Form Dma 5006 - Report Of Medical Examination North Carolina Department Of Human Resources

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