Category II - MER Paper Submission Samples - Current

CLAIMANT:
DDS CASE NUMBER:
DEA: ATE000

DIABETES QUESTIONNAIRE FOR TREATING SOURCE
1. Please include treatment notes, and lab tests
from
to
2. Diagnosis
3. Date of onset of symptoms.
4. Height
Weight

Date

5. Date and results of the latest blood sugar evaluation and glycohemoglobin (HbA1C).

6. If acidosis has occurred on the average of at least once every two months, please
indicate blood chemical test (PH or PCO2 or bicarbonate levels) and the dates
performed.

7. If the patient has sustained an amputation due to diabetic necrosis or peripheral
vascular disease, please describe and indicate the date of the amputation.

8. If present, please describe any visual abnormalities due to diabetes.

9. Is there any evidence of neuropathy? If so, please describe. Is an assistive device
medically required for ambulation? When was it prescribed?
10. Is the Diabetes under satisfactory control?  Yes  No
11. Please describe compliance and response to treatment.

12. Please indicate any other observable conditions or pertinent clinical findings that
might affect the patient's functional abilities.
13. Date first seen:

Date last seen:

Frequency of visits:

Thank you for your cooperation.
Physicians Signature
Date
Phone Number

MSC 223 (07/10)
Page 1 of 1

Print or type name
Best time to call

CLAIMANT:
DDS CASE NUMBER:
DEA: ATE000

Treating Physician
General Medical Evaluation
Directions: Please provide a current assessment using objective findings. This
information is necessary to evaluate this patient’s disability claim. Please indicate if
normal. If abnormal, please list specific findings. (Please use reverse side if
additional space is needed.)
Date of Exam:

Frequency of Visits:

General Appearance
1. Height:

Weight:

Blood Pressure:

2. Best Corrected:

OD _____________

OS ______________

3. If uncorrected give:

OD _____________

OS ______________

Eyes

4. Describe any severe disease/visual defect (including visual fields):

Ears
5. Can your patient hear normal conversation? Yes  No 
If no, please explain.

Respiratory System
6. Lungs:
7. Details of dyspnea, if any:

Cardiovascular
8. Chest pain of cardiac origin? Yes  No 
If yes, please describe, including symptoms:
9. Peripheral vascular pulses:

MSC 234 (07/10)
Page 1 of 2

CLAIMANT:
DDS CASE NUMBER:
DEA: ATE000

Abdominal
10. Abdomen/pelvis findings:

11. Organomegaly? Yes  No 
If yes, please describe.

Musculoskeletal
12. Please provide range of motion (ROM) and describe affected joint(s) and/or spine.

Neurological System
13. Please describe the following:
a.
b.
c.
d.
e.

Gait:
Reflexes:
Sensory:
Motor:
Atrophy? Yes  No 
If yes, please describe.

f. Does your patient have seizures? Yes  No 
If yes, please describe (including frequency).

Comments:
14. Please provide comments below on other conditions your patient has which are not
already described above.

Name of Physician (printed)

Physician Signature

Date ________________ Telephone # and extension: (_______)

MSC 234 (07/10)
Page 2 of 2

CLAIMANT:
DDS CASE NUMBER:
DEA:

ATE000

TREATING SOURCE SUMMARY OF VISION FINDINGS
1. DIAGNOSIS:

OD
OS

2. DISTANCE VISUAL ACUITY:
Without correction (leave blank if not checked): OD

OS

Date

With correction (leave blank if not tested)

OS

Date

OD

Most recent manifest refraction: Date __________ Check here if unknown 
OD _____________________ = 20/_____________
OS _____________________ = 20/_____________
3. Describe any pathological findings:
4. What surgery has been performed? None 
OD

Date

OS

Date

5. Has formal Visual Field testing been done? Check all that apply.
 No.  No significant visual field deficit expected.
 Yes. Was this a reliable field consistent with ocular pathology?  Yes  No
Date of test _________________
Please include the visual field printouts with this report.
6. Indicate earliest date:
Best corrected VA in the better eye was limited to 20/200 or worse:
N/A ____ Date: _________
Residual visual field in the better eye was 20 degrees or less in widest diameter:
N/A ____ Date: _________
Please include supporting clinic notes or VF test results for that date.
7. Please comment on treatment plan and prognosis over the next 12 months:

Signature of:

Physician 

MD/OD Name (please print)

MSC 201 (07/10)
Page 1 of 1

Optometrist 
(
)
Phone No.

Date
Best time to contact you

Cardiac Questionnaire Doctor-Adult

Form Approved
OMB No. 0960-0555
[Standard Header]
Patient Name: {clmt_full_name}

{barcode}

PLEASE COMPLETE AND RETURN BY {mer_return_date}
CARDIAC QUESTIONNAIRE
1) Diagnosis: _________________________

Date of diagnosis: ___________________

2) Date and findings of most recent exam: ___________________________________________
______________________________________________________________________________
3) Would undergoing exercise testing pose significant risk for your patient?

Yes

4) If the patient has chest pain, is it related to a cardiac condition?

No

Yes

No

If no, what non-cardiac condition is causing chest pain? ________________________________
5) Has the patient experienced cyanosis at rest?

Yes

No On exertion?

Yes

No

6) Describe the patient’s cardiac signs and symptoms (for example, dyspnea, fatigue,
palpitations, chest discomfort, edema, varicosities, stasis dermatitis, ulcerations, claudication).
______________________________________________________________________________
______________________________________________________________________________
7) Describe the location, duration, and frequency of the patient’s symptoms. ________________
______________________________________________________________________________
8) Describe any precipitating factors (for example, physical activity, eating, cold air). _________
______________________________________________________________________________
9) What relieves the patient’s symptoms (for example, rest, position, medication)? ___________
______________________________________________________________________________
10) Are the symptoms acute or chronic? _____________________________________________

11) Current New York Heart Association class rating: _________. Based on this rating describe
the patient’s physical limitations (for example, difficulty with household tasks, walking, stairs,
lifting).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12) Describe any evidence of neurological complications (for example, ataxia, paralysis,
aphasia).
______________________________________________________________________________
______________________________________________________________________________
13) Is there evidence of end-organ damage as a result of hypertension (for example, kidney
failure, retinopathy)?
Yes
No
If yes, describe. _________________________________________________________________
______________________________________________________________________________
Treatment:
MEDICATION

DOSAGE AND FREQUENCY

PAST TREATMENT OR
RECOMMENDATION(S) (for example,
angioplasty, CABG, pacemaker)

DATE PERFORMED OR SCHEDULED

14) Have the symptoms persisted despite treatment? __________________________________
______________________________________________________________________________
15) Describe any restrictions to work-related activities, if not previously provided (for example,
walking, lifting, carrying).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
NOTE: Please submit copies of tracings, testing, and laboratory results, if you have not provided
them previously.
___________________________
Physician’s Signature

______________
Date

______________________________
Phone Number

____________________________________________
Printed Name

______________________________
Title

[Paperwork Reduction Act]

Form Approved
OMB No. 0960-0555

Epilepsy Questionnaire Doctor-Adult

[Standard Header]
Patient Name: {clmt_full_name}
{barcode}

PLEASE COMPLETE AND RETURN BY {mer_return_date}
EPILEPSY QUESTIONNAIRE
1) Date of most recent examination: ________________________________________________
2) Diagnoses: __________________________________________________________________
3) Indicate the type of seizures:

Convulsive

Non-Convulsive

4) Dates of last two seizures: __________________ ____

________________________

5) Describe typical seizures (include all associated phenomena, such as aura, loss of
consciousness, tonic or clonic movement, incontinence, alteration of awareness, unconventional
behavior, duration, etc.).
______________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6) Describe postictal manifestations and duration. _____________________________________
______________________________________________________________________________
______________________________________________________________________________
7) If convulsive, when do episodes occur?
Day (with loss of consciousness and convulsive seizures)
8) Seizures witnessed by physician or staff member?

Yes

Night
No

If yes, describe. ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

9) Treatment:
MEDICATION

DOSAGE AND
FREQUENCY

SIDE EFFECT(S)

10) Other treatment: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
11) Are seizures controlled with medication?

Yes

No

If no, explain. __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12) Frequency of seizures after prescribed treatment: ___________________________________
______________________________________________________________________________
______________________________________________________________________________
13) Serum levels:
DRUG

DATE

RESULT

14) If serum drug levels are therapeutically inadequate, explain further. ____________________
______________________________________________________________________________
______________________________________________________________________________

15) Describe any functional limitations resulting from the patient’s condition (for example,
driving, physical activity, hazardous conditions). ______________________________________
______________________________________________________________________________
______________________________________________________________________________
16) Describe any restrictions to work-related activities, if not previously provided (for example,
walking, lifting, carrying). ________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
NOTE: Please submit copies of any testing and laboratory results, if you have not provided them
previously.
___________________________
Physician’s Signature

______________
Date

______________________________
Phone Number

____________________________________________
Printed Name

______________________________
Title

[Privacy Act Statement]
[Paperwork Reduction Act]

Cardiac Questionnaire Doctor-Child
[Standard Header]
Child Name: [ClmFtNm] [ClmLtNm]
[Barcode]

PLEASE COMPLETE AND RETURN BY [CalcReturnDate]
CHILD CARDIAC QUESTIONNAIRE
1. Diagnosis: ________________________

Date of diagnosis: ____________________

2. Date and findings of most recent exam: __________________________________________
___________________________________________________________________________
3. Current height and percentile: __________
4. For children under two:

Current weight and percentile: __________

Birth Length: _____________ Birth Weight: ________________

5. Has the child had involuntary weight loss or failure to gain weight that has persisted for two
months or longer?
Yes
No
If yes, provide copies of records to include
longitudinal history of height, weight, and growth percentiles. ________________________
___________________________________________________________________________
___________________________________________________________________________
6. For children age six or older, would undergoing exercise testing pose significant risk for the
child?
Yes
No
7. If the child has chest pain, is it related to a cardiac condition?
Yes
No
If no, what
non-cardiac condition is causing chest pain? _______________________________________
8. Describe the child’s cardiac signs and symptoms (for example, syncope, cyanosis, edema,
dyspnea, weakness, palpitations, weight loss or gain). _______________________________
___________________________________________________________________________
___________________________________________________________________________
9. Describe the location, duration, and frequency of the child’s symptoms. _________________
___________________________________________________________________________
10. Describe any precipitating factors (for example, physical activity, eating, cold air). ________
___________________________________________________________________________
11. What relieves the child’s symptoms (for example, rest, position, medication)? ____________
___________________________________________________________________________

[Standard footer]

12. Are the symptoms acute or chronic? _____________________________________________
13. Describe any evidence of neurological complications (for example, weakness, spasticity,
incoordination, ataxia, tremor) resulting from the child’s cardiac condition(s).
___________________________________________________________________________
___________________________________________________________________________
14. Is there evidence of end-organ damage as a result of hypertension (for example, kidney
failure, retinopathy)?
Yes
No If yes, describe.______________________________
___________________________________________________________________________
15. Describe any cognitive deficits resulting from the child’s cardiovascular disease or
treatments for the cardiac condition(s). _____________________________________
___________________________________________________________________________
___________________________________________________________________________
16. Treatment:
MEDICATION

DOSAGE AND FREQUENCY

PAST TREATMENT OR
RECOMMENDATION(S) (for example,
pacemaker, defibrillator, corrective surgery)

DATE PERFORMED OR SCHEDULED

17. Have the symptoms persisted despite treatment? ___________________________________
___________________________________________________________________________
18. Describe any restrictions to age appropriate activities, if not previously provided (for
example, acquiring and using information, attending and completing tasks, interacting and
relating with others, moving about and manipulating objects, self-care).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

NOTE: Please submit copies of tracings, testing, and laboratory results, if you have not provided
them previously.
.

[Standard footer]

______________
Date

______________________________
Phone Number

____________________________________________
Printed Name

______________________________
Title

___________________________
Physician’s Signature

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a) and 1631(d) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on the claimant’s eligibility for benefits.
We will use the information to make a determination of eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies for administering cash or non-cash income maintenance
or health maintenance programs; and
2. To contractors, and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
contemplate disclosing information under this routine use only in situations in which SSA
may enter a contractual or similar agreement with a third party to assist in accomplishing
an agency function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0044, entitled National Disability Determination Services File System and 60-0089,
entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
(OMB) control number. We estimate that it will take about 12 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.