Va Form 10-10m - Medical Certificate
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3CONTINUE ON BACK WHEN NECESSARY
MEDICAL CERTIFICATE
AM
1. DATE
2. TIME
3. AGE
4. SEX
5.ON ARRIVAL PATIENT WAS:
6. PHONE NUMBER
7. HOMELESS
PM
M
F
AMBULATORY
STRETCHER
WHEELCHAIR
YES
NO
8A. ALLERGIES
8B. WEIGHT
8C. TEMPERATURE
8D. PULSE
8E. RESPIRATION
8F.B/P
8G. DUE TO INJURY
NO
YES
9. CURRENT MEDICATIONS
10. TRIAGE
11. SIGNATURE
12. HISTORY AND PHYSICAL
13. DIAGNOSTIC IMPRESSIONS
14. PLAN
15A. ATTENDING OF RECORD
15B. EXAMINER’S SIGNATURE
SECTION II - FOR PATIENT
1. DISPOSITION/CLINIC APPOINTMENT
2. AFTER CARE SHEET GIVEN
3. FOLLOW UP - ACTIVITY - LIMITATIONS
YES
NO
4. CONDITION
5. DATE/TIME OF DISCHARGE
6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED
SATISFACTORY
UNCHANGED
IMPRINT PATIENT DATA CARD
7. PATIENT INSTRUCTIONS
I CERTIFY THAT I RECEIVED AND
8. PATIENT’S SIGNATURE
UNDERSTAND THESE INSTRUCTIONS
VA FORM
10-10M
DEC 2016
SUPERSEDES VA FORM10-10M, MAY1990, WHICH WILL NOT BE USED.
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