DMA -5006 (Rev. 10/91)
STATE OF NORTH CAROLINA
(DSS - 1653)
DEPARTMENT OF HUMAN RESOURCES
REPORT OF MEDICAL EXAMINATION REQUESTED BY
________________________ COUNTY DEPARTMENT OF SOCIAL SERVICES
Part I. (To be filled in by county DSS) Case No. ________________________________________
Name of patient ________________________________________ Dist No. __________________
Address ________________________________________________________________________
Age or birthdate _____________________________ / SSN ______________________________
______________________ __________
Date Director of Social Services
Part II. (For Applicant, Recipient, Personal Representative or Guardian)
I hereby authorize any physician, hospital, or clinic who has treated or examined me to give the county
Department of Social Services and the Disability Determination Section, Department of Human
Resources, information about my present or past condition of health.
_______________________ __________
Date Signature of Applicant, Recipient, Personal
Representative or Guardian
Part III. (Medical Report) Note to physicians/psychologists: Please complete this form giving sufficient
details to enable a reviewing physician to make an independent determination as to the severity and
duration of the impairments. This form is provided for your convenience. The substitution of a narrative
report is acceptable. In addition, copies of office notes, hospital discharge summaries and especially,
reports of laboratory studies, x-rays and other objective studies for at least the previous 12 months are
needed. A signed consent for release of information is attached.
A. Complaint (In patient's own words) ________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Date of Onset ______________________ Date of First Examined _______________________
Frequency of Visits __________________ Date of Most Recent Examination _______________
History ______________________________________________________________________
B. Findings on Examination:
General Appearance _______________ Posture ______________
Gait _________________
Height ___________ Weight ___________
Cardio-Vascular System:
(1) Blood Pressure ___(Systolic)_____
Pulse Rate __________ Rhythm ___________
(Diastolic)
(2) Heart: Size ___________ Sounds ___________
(3) Edema _____________
(4) Dyspnea ___________ ( ) At rest ( ) On slight exertion ( ) On moderate exertion
(5) Angina _____________ ( ) At rest ( ) On slight exertion ( ) On moderate exertion
(6) Functional capacity (American Heart Assn.) Class I _____ II _____ III _____ IV _____
(7) Report of ECG: ______________________________________ Date ________________
(8) Degree of Arteriosclerosis, if present: ___________________________________________
Figure 3
