I/EDR:10 2025

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41 votes

The document is a physical assessment form used by the Monroe County Department of Human Services to evaluate an individual's employability. It requires completion of various sections including client identification, medical history, current medications, and functional limitations. The form also includes an authorization for the release of medical information and outlines different levels of employability based on the client's condition. Medical professionals are required to complete and sign the form.

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Click ‘Get Form’ to open the I/EDR:10 in the editor.
Begin by filling out the 'Client Identification' section. Enter the client's name, address, DHS case number, last four digits of their SSN, and date of birth.
Indicate whether the client is a veteran and if they have an active SSI/SSD application pending. Provide the date they became a patient at your practice.
Complete the 'Authorization for Release of Medical Information' section by signing and dating where indicated.
In the 'Employability' section, select one of the four statements that best describes the individual's condition and provide any necessary elaboration.
Fill out medical history details under sections (A) through (E), including past medical conditions, hospitalizations, current medications, and physical examination findings.
Finally, ensure that a qualified medical professional completes and signs the form in the 'Medical Professional’s Information' section before submission.

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Versions	Form popularity	Fillable & printable
2014	4.3 Satisfied (41 Votes)

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