Required Medical Evidence for Specific Conditions

 

 

  Disorder of the Thyroid gland must have the following reported within the past year before impairment rating can take place:

*       Note from Physician with the following information:

    Current symptoms

         Physical exam findings of the area(s) affected

    Any Biopsy information

    Surgical history of site

 

  Anemia must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

         Current symptoms

         Need for transfusion and the intervals involved

         Current treatment(s) including prescriptions

o    Complete Blood Count with differential (CBC with Diff)

 

  Tremor must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the area(s) affected:

o    Motor strength

o    Coordination

o    Dexterity

                                             Functional Activity pertaining to Activity of Daily Living (ADL):

o    Buttoning shirt

o    Lacing shoes

o    Performing peg tasks

         Current treatment(s)

 

 Peripheral Neuropathy, Polyneuropathy must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the Upper Extremities

o    Motor strength

o    Coordination

o    Dexterity

         Functional Activity pertaining to Activity of Daily Living (ADL):

o    Buttoning shirt

o    Lacing shoes

o    Performing peg tasks

         Physical exam findings of the Lower Extremity

o    Motor strength

o    Coordination

         Functional Activity pertaining to Activity of Daily Living (ADL): (Upper extremities)

o    Standing (with/without mechanical support and/or assistive device)

o    Walking

  With/without assistance

  Ability to start and stop walking

  Limited to level surface

  Difficulty with elevation/stairs

 

o    Loss of stature

o    Romberg Sign

         Current treatment(s)

*       Electromyography (EMG)

 

 Cataracts must have the following reported within the past year before impairment rating can take place:

Note from Physician with the following information:

*       Current symptoms

         Physical exam findings

         Current treatment(s)

         Surgical procedure(s)

*       Visual Acuity testing, corrected

*       Visual Field testing

 

Hearing loss must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

    Current symptoms

         Physical exam findings of the area(s) affected

*       Tympanometry

*       Speech Discrimination test

Pure Tone Audiogram of both ears

 

Chronic Sinusitis must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

    Current symptoms including: headaches, balance problems

         Physical exam findings of the area(s) affected

    Current treatment(s) including prescriptions

*       Sinus CT

 

Allergic Rhinitis must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

    Current symptoms including headaches, balance problems

         Physical exam findings of the area(s) affected

    Current treatment(s) including prescriptions

 

Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Bronchitis, Asbestosis, Chronic Respiratory condition must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information

         Current symptoms

         Physical exam findings of the area(s) affected

         Current treatment(s) including prescriptions

*       Pulmonary Function Test (PFT) with DLCO with pre/post bronchodilator

 

 Liver Disease must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the area(s) affected

         Any Biopsy information

         Surgical history of site

         Nutritional Status and/or restrictions

         Current treatment(s) including prescriptions

*       Liver Function Test (LFTs)

 Upper Genitourinary Disease must have the following reported within the past twelve months before impairment rating can take place:

 

*       Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the area(s) affected

         Any Biopsy information

         Surgical history

         Current treatment(s) including prescriptions

         Need for Dialysis and its schedule

         Nutritional Status and/or restrictions

*       Kidney Function Test (Creatinine Clearance Test)

*       Serum Creatinine

*       Urine Analysis

 

 Bladder Disease must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

         Current signs/symptoms (frequency, nocturia, loss of control, urgency, dribbling)

         Physical exam findings of the area(s) affected

         Any Biopsy information

         Surgical history

         Current treatment(s) including prescriptions

 

 Dermatitis, Skin Rash must have the following reported within the past twelve months before impairment rating can take place:

*       Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the area in question

         Activities of Daily Living (ADLs)

         Current treatment(s)

         Patch testing information when available


 

Cancers

(in alphabetical order)

 

All information has to be dated in the past 12 months including the diagnostic tests.

 

 Bladder Cancer

* Note from Physician with the following information:

         Current symptoms to include urinary frequency/nocturia, reflex activity of the bladder

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs)

         Current treatment(s)

 

Breast Cancer

 * Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs)

         Current treatment(s)

 

Colon Cancer

 * Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Presence of any stomas

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

 

Esophageal Cancer

 * Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Presence of any stomas

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

 

Gallbladder Cancer

  Note from Physician with the following information:

         Current symptoms including weight loss and percentage, and jaundice

         Presence of any stomas

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

*       Liver Function Tests (LFTs)

 

Hodgkins Lymphoma

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs)

         Current treatment(s)

*Complete Blood Count (CBC) with differential

*Pathology report if available

 

Hypo-pharyngeal Cancer

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Presence of any stomas

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency

 

Laryngeal Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings

         Surgical history to the area

         Presence of any stomas

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency

 

Leukemias (includes Acute/Chronic Lymphocytic Leukemia (ALL/CLL) and Acute/Chronic Myelocytic Leukemia (AML/CML))

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings including any liver or spleen abnormalities

         Activities of Daily Living (ADLs)

         Current treatment(s)

*       Complete Blood Count (CBC) with differential

*       Liver Function Tests (LFTs)

 

 

Liver Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage, presence of jaundice

         Physical exam findings of the area(s) affected including presence of ascites

         Surgical history to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

*                                                                   Liver Function Tests (LFTs)

 

Lung Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings

         Surgical history to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

*       Pulmonary Function Test (PFT)

 

Multiple Myeloma

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings including any spleen abnormalities

         Activities of Daily Living (ADLs)

         Current treatment(s)

*       Complete Blood Count (CBC) with differential

 

Myelodysplastic Syndrome

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings including any spleen abnormalities

         Activities of Daily Living (ADLs)

         Current treatment(s)

*       Complete Blood Count (CBC) with differential

 

Nasal Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings

         Surgical history to the area

         Presence of any stomas

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency

 

Nasopharyngeal

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Presence of any stomas

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency

 

Kidney Cancer

See Renal Cancer

 

Pancreatic Cancer

  Note from Physician with the following information:

         Current symptoms including weight loss and percentage, and jaundice

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

*       Liver and Pancreatic Function Tests

 

Pharyngeal Cancer

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Presence of any stomas

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency

Polycythemia Vera

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings including any spleen abnormalities

         Activities of Daily Living (ADLs)

         Current treatment(s)

*       Complete Blood Count (CBC) with differential

 

Prostate Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage along with urinary control and sexual function after surgery if prostatectomy was performed

         Physical exam findings including pain induced by metastatic lesions

         Activities of Daily Living (ADLs)

         Surgical history to the affected area

         Current treatment(s)

 

Renal Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings

         Need for dialysis and schedule

         Kidney transplant

         Surgical history to the affected area

         Presence of any stomas

         Activities of Daily Living (ADLs)

         Current treatment(s)

*       Kidney Function Test (Creatinine Clearance Test)

*       Serum Blood Urea Nitrogen (BUN) and Creatinine

*       Urine Analysis

 

Skin Cancer

*       Note from Physician with the following information:

         Current symptoms

         Physical exam findings of the area(s) affected

         Physical exam findings of the area in question

         Activities of Daily Living (ADLs)

         Current treatment(s)

 

Small Intestinal Cancer (duodenum, jejunum, ileum)

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Presence of any stomas

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

 

Thyroid Cancer

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs)

         Current treatment(s) and presence of other illnesses allowing for only partial hormone replacement

 

Tongue Cancer

*       Note from Physician with the following information:

         Current symptoms including weight loss and percentage

         Physical exam findings of the area(s) affected

         Remission status and number of years in remission

         Surgical History to the area

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency

 

Tracheal Cancer

*       Note from Physician with the following information:

         Current symptoms including nutritional status, weight loss and percentage

         Physical exam findings

         Surgical history to the area

         Presence of any stomas

         Activities of Daily Living (ADLs) to include any limitation on diet

         Current treatment(s)

         Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

  Audibility

  Intelligibility

  Functional Efficiency