|
Disability Examination Worksheets
|
Scars
| Name: |
SSN: |
| Date of Exam: |
C-number: |
| Place of Exam: |
A. Review of Medical Records: B.
Medical History (Subjective Complaints):
- Type of injury or infection causing the wound or scar, its date.
- Current symptoms.
C. Physical Examination (Objective Findings):
For every scar to be examined, address EACH of the following
and fully describe the current findings. Note that, in addition to
measuring the scar itself, measurements of areas with certain abnormal
characteristics must also be provided. All measurements should be reported
in inches or centimeters.
- Describe precise location of each scar. Draw diagram if
necessary.
- Give MEASUREMENT of length and width (at its widest part) of
each scar.
- Is there pain in the scar on examination?
- Is there adherence to underlying tissue?
- Texture of skin. If irregular, atrophic, shiny, scaly, etc.,
give MEASUREMENT of length and width of area so affected.
- Is the scar unstable, meaning is there frequent loss of
covering of skin over the scar, such as from ulceration or breakdown of
skin?
- Is there elevation or depression of the surface contour
of
the scar on palpation?
- Is the scar superficial (meaning there is no underlying
soft
tissue damage)?
- Is the scar deep (meaning there is underlying soft tissue
loss or damage)? If yes, give MEASUREMENT of length and width of underlying
soft tissue damage.
- Describe any inflammation, edema, or keloid
formation.
- Describe color of scar compared to normal areas of skin
(give
MEASUREMENT of length and width of any hypopigmentation or
hyperpigmentation).
- For face, discuss whether there is gross distortion or
asymmetry of any feature or set of paired features (nose, chin, forehead,
eyes (including eyelids), ears (auricles), cheeks, lips).
- Is there an area of induration and inflexibility of skin in
the area of the scar? If so, give MEASUREMENT of length and width of area
of induration.
- Describe any limitation of motion or other limitation of
function caused by a scar.
- With disfigurement or disfiguring scar of head, face, or
neck, submit COLOR PHOTOGRAPHS.
D. Diagnostic and Clinical Tests:
Include results of all diagnostic and clinical tests
conducted in the examination report. E.
Diagnosis:
| Signature: |
 |
Date: |
 |
|
|
|
Reviewed/Updated Date:
May 1, 2007
|
|