Disability Examination Worksheets
Intestines (Large and Small)
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A. Review of Medical Records: B.
Medical History (Subjective Complaints):
Comment on:
- Weight gain or loss.
- Nausea and/or vomiting.
- Constipation, diarrhea (frequency, severity, duration, and
episodic or not?).
- For fistula - frequency, duration, and amount of fecal
discharge.
- Treatment - type, duration, response, side effects.
- Abdominal pain, distress, cramps - frequency, duration, location.
- For ulcerative colitis - number of attacks per year.
- Effects of condition on occupational functioning and activities of daily living.
- History of trauma.
- History of hospitalizations or surgery - reason or type of surgery, location and dates, if known.
- History of neoplasm:
- Date of diagnosis, diagnosis.
- Benign or malignant.
- Treatment, dates and response.
- Last date of treatment.
C. Physical Examination (Objective Findings):
Address each of the following and fully describe current
findings:
- Malnutrition, other evidence of debility.
- Abdominal pain - location.
- For fistula - location, presence of discharge.
- Ostomy present- type.
- Abdominal mass.
- Signs of anemia.
- Weight - gain or loss.
D. Diagnostic and Clinical
Tests:
1. If signs of anemia, obtain hemoglobin/hematocrit. 2. Include results of all diagnostic and clinical tests
conducted in the examination report. E. Diagnosis:
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Reviewed/Updated Date: December 15, 2008 |
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