Form Dhcs 7045 - California Worker Observations Disability - Health And Human Services Agency
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1State of California—Health and Human Services Agency
Department of Health Care Services
WORKER OBSERVATIONS—DISABILITY
Applicant
Social security number
Check appropriate responses and explain in “remarks” where necessary.
1. Did this person appear:
Pale
Jaundiced (yellow)
2. Was this person wearing a hearing aid?
Yes
No
3. Was this person wearing glasses?
Yes
No
During the interview, did this person use a magnifying glass?
Yes
No
4. Did this person:
a. Use a cane?
Yes
No
b. Use a wheelchair?
Yes
No
c. Use a walker?
Yes
No
d. Walk with a limp?
Yes
No
If yes,
Right
Left
5. Did this person:
a. Appear to have an injury?
Yes
No
If yes, explain below.
b. Appear to be confused/disoriented?
Yes
No
If yes, explain below.
c. Have a noticeable breathing difficulty?
Yes
No
Remarks:
Eligibility Worker
Date
DHCS 7045 (05/07)
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Parent category: Legal