Illinois Department of Human Services caseworkers send this nine-page report when someone applying for cash or medical assistance claims a physical or mental impairment. The physician records findings by body system, then rates the person's physical and mental ability to do work-related activities on a regular and continuous basis. The IDHS Client Assessment Unit reviews it with the caseworker's social information form to decide TANF medical barriers and AABD disability.
The IDHS Family Community Resource Center fills in the header with the client's name, case number and office. The physician completes Section 1, the Section 2 body systems that apply, the Section 3 physical and Section 4 mental capacity ratings and the signature; a psychiatrist or psychologist may complete it for mental conditions.
The IDHS office enters the date, the client's name and address, the case number and its own office details. The printed instructions ask you to complete Section 1 and any later sections that relate to the patient's diagnosis, symptoms and complaints, to stress your opinion on work-related abilities in Sections 3 and 4, and to attach records from the past 12 months. Return the form to the office shown.
Enter the dates last examined and first seen, visit frequency, and hospitalizations in the last 12 months with approximate dates and reasons. Record height, weight, BMI, blood pressure, respiratory rate, pulse and general appearance, then the chief complaints with dates of onset. Give the complete diagnosis, including the DSM code for mental impairments if known, and significant lab results with dates, such as H/H, sed rate, ANA, RF, creatinine and bilirubin.
Complete only the systems that apply. Vision needs corrected and uncorrected acuity measured with current manifest refraction. Hearing asks for air and bone conduction results with a copy of the test, aided status and any cochlear implant. Cardiovascular covers heart findings, chest pain, dyspnea, syncope, edema, EKGs with tracings, AHA functional class and ejection fraction with its source and whether measured during stability or exacerbation. Respiratory asks for clinical signs, pre- and post-bronchodilator FVC and FEV1, DLCO and oxygen saturation on room air.
Each remaining system (digestive, genitourinary, endocrine, hemic and lymphatic, neoplastic disease, HIV infection and immune system, neurological, musculoskeletal, skin) asks for objective findings, dated test results, treatment and response. Specific prompts include the expected delivery date for pregnancy, acidotic episodes and neuropathy for diabetes, pathology reports for cancer, opportunistic infections for HIV, seizure frequency, description, medication levels and compliance, and joint range of motion in degrees from neutral.
Rate lifting and carrying at weights from under 10 to 100 pounds as never, occasionally, frequently or continuously, using the printed definitions. Give hours the person can sit, stand and walk at one time, note any cane or walker, and rate reaching, handling, fingering, feeling and push/pull for each hand, foot controls, postural activities and environmental exposures. Answer the hearing and vision questions, then the daily-activity questions, such as shopping, travel and meal preparation, based solely on the physical impairment.
List any other work-related activities affected, such as a need to lie down during the day, be absent from work or shift position at will. Identify the medical or clinical findings that support each limitation and explain why; IDHS says the usefulness of your assessment depends on this. Give the month and year the limitations first appeared, if you can, and whether they have lasted or will last 12 consecutive months.
Rate nine abilities on a sustained basis as none, mild, moderate, marked or extreme, using the printed definitions: understanding, remembering and carrying out simple and complex instructions, making judgments, interacting with the public, supervisors and co-workers, and responding to changes in a routine work setting. Describe other affected capabilities, the findings that support your ratings, when the limitations began and whether alcohol or substance use contributes.
Sign and print your name, and enter the date of examination, telephone number and medical specialty. IDHS instructions also ask you to name the person the review team can contact for more information about the client, which can be you or a responsible individual working under your direction.
Download the current version from the source each time; forms change without notice.
Medical Evaluation - Physician's Report
Evaluación Médica - Informe del Médico
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The caseworker forwards it to the IDHS Client Assessment Unit, whose review team usually bases its disability decision on the medical and psychological information you provide. Team members sometimes need to discuss a case with someone who knows the client, so IDHS asks you to identify a contact, either yourself or a responsible person working under your direction.
IDHS asks for copies of office progress notes, test results, x-ray reports and any other relevant medical records from the past 12 months. Several body-system items ask for specific attachments too: EKG tracings, hearing test results, echocardiogram or other ejection fraction reports, and pathology reports for neoplastic disease. Attach any additional information you think would help the disability determination.
Yes. IDHS publishes a Spanish version, Evaluación Médica - Informe del Médico, as form IL444-0183AS. It asks for the same findings and functional ratings as the English IL444-0183A and goes back to the same Family Community Resource Center office.
The last question in Section 4 asks whether alcohol or substance use contributes to any of the limitations you rated. If it does, identify which ones and explain how your answers would change if the person were totally abstinent from alcohol and substance use.