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Government of the District of Columbia Department of Human Services Income Maintenance Administration

MEDICAL EXAMINATION REPORT

Customer/Patient Name: Date of Birth:

Address: Phone:

Physician’s Name: Address:

Agency: Phone:

The information provided in this form will be used to determine eligibility for benefits requiring a finding of disability under the Social Security disability criteria. Please focus your responses on the patient’s ability to perform work functions.

Physical Examination Report (To be completed by a medical professional):

Date of exam: Height: Weight:

Medical Conditions, Clinical Manifestations, and Diagnosis: (Please include ICD-9 Codes or DSM-IV Codes and avoid abbreviations as much as possible):

Describe Objective Findings, Clinical Findings and your treatment recommendations: (Especially since we do not see the individual and need your observations. Please include all of the patient’s positive test results and signs found during examination.):

(DHS 856 proposed rev. 08/04) (over) For DHS Use Only Worker:

Case #:

MRT Doctor Reviewer: