G-250 Medical Assessment

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0038

MEDICAL ASSESSMENT
SECTION 1 - Instructions
Some items on this form will not apply to you and you will not need to answer them. Based on your
answer to a question, you may be told to skip to another item number, or even another section. Follow
the instructions that tell you to “Go to” another item. These are designed to save you time and help you
move through this Medical Assessment quickly, filling in only necessary information. If no “Go to”
instructions are given, answer the next item in order. Do not skip any items unless directed to do so.
Enter “NA” for not affected or “UNK” for unknown, as appropriate.
Please read the Important Notices on page 7.

SECTION 2 - Patient Identification
Railroad Retirement Claim Number
Social Security Number
Name
Address

,

Telephone Number

(

)

SECTION 3 - General Information
1

Enter the date you began treating the patient.

2

Enter the date of the last examination.

3

Enter the patient's weight and height.

Month

Day

Year

Month

Day

Year

_____________________ Weight
_____________________ Height

SECTION 4 - Musculoskeletal System
4

A

Enter an "X" in the appropriate box:
Is the musculoskeletal system normal?

5

YES - Go to Section 5A
NO - Go to Item 4B

B

Describe the impairment. Attach a copy of any x-ray reports, MRI reports, CT scan reports, etc.

A

Enter an "X" in the appropriate box:
Is there a limitation of motion in the spine or
any joints?

YES - Check this box then go to Item 5B
and enter either:
• the range of motion or
• an "N" for normal range of
motion
NO - Check this box then go to Item 6
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B
CERVICAL SPINE
Flexion

Normal
Degrees

Actual
Degrees

45
45

Extension

30

Right Lateral Flexion

45

Right Lateral Flexion

30

Left Lateral Flexion

45

Left Lateral Flexion

30

Right Rotation

60

Left Rotation

60
Right

Left

Right

150

Abduction

40

Forward Elevation

150

Adduction

20

Internal Rotation

80

Flexion

External Rotation

80

Extension

30

Internal Rotation

40

External Rotation

50

Flexion

150

Left

100

KNEE

Extension

0

Supination

80

Flexion

Pronation

80

Extension

WRIST

7

HIP

Abduction

ELBOW

Actual
Degrees

90

Extension

SHOULDER

6

DORSOLUMBAR SPINE
Flexion

Normal
Degrees

150
0

ANKLE

Dorsi-Flexion

60

Dorsi-Flexion

20

Palmar-Flexion

70

Plantar-Flexion

40

Enter an "X" in the appropriate box:
Are there paraspinal muscle spasms present on
examination?
Describe muscle strength on a graded scale (0 to 5/5).

YES
NO

Lower Extremity (Name left or right joint or muscle group and grade):
Upper Extremity (Name left or right joint or muscle group and grade):
8

Describe reflexes on a graded scale (0 to 4+) and describe any sensory abnormalities.
Lower Extremity (Name left or right joint or muscle group and grade):
Upper Extremity (Name left or right joint or muscle group and grade):

9

A

Describe, in detail, the patient's gait and station.

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B

Enter an "X" in the appropriate box:

YES - Go to Item 9C
NO - Go to Item 10

Does the patient walk with an assistive
device?

10

C

How far can the patient walk without using an assistive device?

A

Enter an "X" in the appropriate box:
Are there any abnormalities in the patient's
hands or fingers?

B

YES - Go to Item 10B
NO - Go to Section 5

Describe any restrictions in the patient's ability to perform gross and fine manipulations. For
example, can the patient pick up a pencil or turn a door knob, etc.? Quantify grip strength on a
graded scale.

SECTION 5 - Cardiovascular System
11

A

Enter an "X" in the appropriate box:

YES - Go to Section 6
NO - Go to Item 11B

Is the cardiovascular system normal?
11

B

Describe the impairment. Provide any signs of decompensation (edema, cyanosis), etc. Describe
any chest pains including character, location, radiation, frequency, duration, precipitating factors,
relieving factors, and associated symptoms. Attach a copy of any EKG tracings, x-ray reports,
etc.

12

Describe any signs of congestive heart failure.

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Describe any rhythm disturbances.

14

Describe any evidence of arterial or venous insufficiency (e.g., intermittent claudication, pulse deficits,
brawny edema, etc.).

SECTION 6 - Respiratory System
15

A

Enter an "X" in the appropriate box:

YES - Go to Section 7
NO - Go to Item 15B

Is the respiratory system normal?
B

Provide detailed objective findings. Attach a copy of any pulmonary function test (including
tracings), x-ray reports, or sputum culture results.

SECTION 7 - Neurological System
16

A

Enter an "X" in the appropriate box:

YES - Go to Item 16B
NO - Go to Section 8

Is there a neurological impairment?
B

17

Describe, in detail, any abnormal neurological findings.

Describe the character, the frequency of attack and the response to medication of any convulsive or
seizure disorder.

SECTION 8 - Vision/Hearing/Speech
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A

Enter an "X" in the appropriate box:
Is the patient's vision, hearing, and speech
normal?

YES - Go to Section 9
NO - Go to Item 18B

B

If there is a vision impairment, provide information about any deficiency in central visual acuity
(before and after correction), peripheral visual fields, or other function. Attach a copy of the
visual field charts.

C

If there is a hearing impairment, describe the limitations in the patient's hearing. Attach a copy
of any audiometric charts.

D

If there is a speech impairment, describe any abnormalities in the patient's speech.

SECTION 9 - Mental Functions
19

A

Enter an "X" in the appropriate box:

YES - Go to Item 19B
NO - Go to Section 10

Does the patient have a severe mental
impairment?
B

Describe the impairment, including emotional reactions, conduct disturbances, orientation, insight,
judgment, hallucinations, delusions, memory for recent and remote events, and evidence of mental
deterioration. Note any changes in the patient's normal activities of daily living. List medication(s)
and response.

SECTION 10 - Other Systems and Impairments
20

A

Enter an "X" in the appropriate box:

YES - Go to Item 20B
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B

Are there any impairments in other systems?
NO - Go to Section 11
Describe the impairment and provide any relevant findings.

SECTION 11 - Exertional Restrictions
21

A
B

Enter an "X" in the appropriate box:

YES - Go to Item 21B
NO - Go to Section 12
Are there any exertional restrictions?
Describe, in detail, any type of exertional restriction (e.g., limitations on lifting, standing, walking,
sitting, stooping, crouching, climbing, etc.)

SECTION 12 - Environmental Restrictions
22

A
B

Enter an "X" in the appropriate box:

YES - Go to Item 22B
NO - Go to Section 13
Are there any environmental restrictions?
Describe any environmental restrictions (e.g., can the patient work around heights, around
machinery, walk on uneven terrain, be exposed to dust, fumes, noise, vibration, temperature
extremes etc.?).

SECTION 13 - Certification

With the understanding that section 13 of the Railroad Retirement Act (45 U.S.C. 231I) provides that anyone
who makes false or fraudulent statements or claims for the purpose of causing an award or payment under
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the Railroad Retirement Act is subject to a fine of up to $10,000, or imprisonment of up to one year, or both, I
certify that the information I have furnished is correct to the best of my knowledge.
Signature (This report must be signed. A stamped signature is not acceptable)

Date

Printed Name and Title

National Provider Identifier

Address and Daytime Telephone Number
Area Code

Telephone Number

Please return this form along with copies of your office records to:

RAILROAD RETIREMENT BOARD

OFFICE OF PROGRAMS/POLICY & SYSTEMS
844 NORTH RUSH STREET

CHICAGO, IL 60611-1275

IMPORTANT NOTICES
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
The information requested on this form is authorized by Section 7(b)(6) of the Railroad Retirement Act. While
you are not required to respond, your cooperation is needed to provide information necessary to complete
processing for the claimant named and to determine the claimant's entitlement to disability benefits under the
Railroad Retirement Act.
We estimate this form takes an average of 30 minutes per response to complete, including time for reviewing
the instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Federal agencies may not conduct or sponsor, and respondents
are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish,
send comments regarding the accuracy of our estimate or any other aspect of this form, including
suggestions for reducing completion time, to Associate Chief Information Officer for Policy and Compliance,
Railroad Retirement Board, 844 N. Rush Street, Chicago, IL 60611-1275.
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICES
The Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) requires the Railroad Retirement
Board to advise you that information you have provided may be used, without your consent, in automated
matching programs. These matching programs are a computer comparison of RRB records with records kept
by other Federal, state, or local governmental agencies. Information from the programs can be used to
establish or verify a person’s eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.

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RRB Form G-250 (01-21)