Application For A Disability Allowance Page 8
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124. Current history: (Please check the appropriate categories)
Extremities and Back
Peripheral Spinal Nerves
Central Nervous System
Respiratory System
Cardiovascular System
Hematopoietic System
Visual System
Ear, Nose, Throat
Digestive System
Reproductive/Urinary System
Endocrine System
Skin
Mental Illness
5. Describe Symptoms and Signs, onset and duration:
6. Abnormal Physical Findings:
7. Diagnosis and Degree of Impairment of function
8. Course of treatment, Current Treatment plan, Patient Response
9. Current Medications
10. Clear Statement Regarding “Disabled” Status
Name of Physician(Signature)/Date:
Name of Physician(Type or Print):
Physician’s Specialty:
Connecticut Medical License #:
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