Form Dma 5006 - Report Of Medical Examination North Carolina Department Of Human Resources Page 2
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1
2Is there any abnormality
Yes
No
Describe Any Abnormal Findings
of the following:
1. Eyes
2. Ears
3. Nose, Throat, Mouth
4. Breasts
5. Lungs
6. Abdomen
7. Hernia
8. Varicose Veins
9. Skin
10. Genitro-Urinary
11. Gynecological
12. Ano-Rectal
13. Endocrine System
14. Lymphatic System
15. Bones, Joints, Muscles
16. Nervous System
17. Mental Status
18. Blood, as Anemia, Leukemia
19. Other
D. LABORATORY AND SPECIAL STUDIES: Give results of all pertinent studies with dates.
_____________________________________________________________________________
_____________________________________________________________________________
E. Diagnosis:
1. Major impairments: _____________________________________________
2. Minor impairments: _____________________________________________
F. Do you believe further diagnostic examination is indicated? _____________________________
If "Yes", describe in detail _______________________________________________________
_____________________________________________________________________________
G. Is there evidence of any impairment not covered above? (Describe) ______________________
_____________________________________________________________________________
H. What restrictions on activities are imposed by impairment? ______________________________
_____________________________________________________________________________
I.
Is any treatment (medical or surgical) recommended to correct or improve major impairment?
_____________________________________________________________________________
J. Prognosis and remarks: _________________________________________________________
K. Work capacity:
( ) Full Time
( ) Part Time
( ) None
Should work be restricted as to: Type ______________ Hours per Day __________________
Estimated period individual will be unable to return to work: ________________________________
Reporting Physician's Name and Address
Signature of Physician
Degree
(Please Type or Print)
Telephone No
Date of this report
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