STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

HEALTH QUESTIONNAIRE

DR 218 (Rev. 04/03)

Date

Applicant's Name

Social Security Number

XXX - XX - XXXX	Insurance Coverage

Medi-Cal#

Medicare#

Other:	#
Sex

Male	Female	Height

Weight

I.	APPLICATION REVIEW - Disability(ies) and functional limitation(s) reported on application:

II.	REVIEW OF CURRENT HEALTH STATUS - Please explain any YES answer in COMMENTS section below.

BODY SYSTEMS - Are you now receiving or have you ever received medical treatment for:

FUNCTIONAL LIMITATIONS - Is your activity or ability to work currently limited by:
NO	YES	WHEN
NO	YES
1.	Ear(s)/Hearing Problem
19.	Your Hearing
2.	Eye(s)/Visual Problem
20.	Your Vision
3.	Mental/Emotional Problem
21.	Your Ability to Learn/Read
4.	Nervous Problem
22.	Your Ability to Speak
5.	Lung/Respiratory Problem
23.	Problem Breathing/Coughing
6.	Heart/Circulation Problem
24.	Dizziness/Fainting
7.	Digestive Problem
25.	Emotional Problems
8.	Kidney/Bladder Problem
26.	Weakness (State Where)
9.	Legs/Feet/Arms/Hands Problem
27.	Numbness (State Where)
10.	Back Problem
28.	Pain (State Where)
11.	Thyroid
29.	Your Memory
12.	Diabetes
30.	Your Ability to Concentrate
13.	Skin Problem
31.	Spells of Unconsciousness
14.	High Blood Pressure
32.	Seizures
15.	Joint Problem
33.	Problem Balancing
16.	Arthritis/Rheumatism
34.	Problem Walking
17.	Suppressed Immune System
35.	Problem Using Hands/Arms/Legs (Specify)
18.	Other (Specify)
36.	Problem Lifting

COMMENTS:

Explain any YES answers in the space below.

Please indicate the specific item number to which you are referring, the specific problem(s)/area(s) affected, and, if undergoing treatment, the name and address of the provider, if other than listed in Sections E, F, or G on the reverse.

Attach additional sheets if necessary.	37.	Problem Bending
38.	Problem Standing
39.	Problem Climbing
40.	Problem Crawling
41.	Problem Kneeling
42.	Problem Sitting
43.	Difficulty with Driving
44.	Other (Specify)
(OVER)

STATE OF CALIFORNIA	DEPARTMENT OF REHABILITATION

HEALTH QUESTIONNAIRE

DR 218 (Rev. 04/03) REVERSE	Attach additional sheets if necessary

III.	ADDITIONAL MEDICAL DATA - If not applicable, indicate N/A
A.	Indicate if you now or in the past have smoked, abused alcohol, or used drugs (illegal or abused legal). State specifics, including what, amounts, and when:

B.	Do you have allergies?	No	Yes If yes, list:

Does this create an interference with your ability to work?	No	Yes If yes, how:

C.	MEDICATIONS - List medicines you are now taking:

Do any of these medications interfere with your ability to work?	No	Yes If yes, explain:

D.	Have you had any operations or broken bones?	No	Yes If yes, provide specifics and dates:

Are there residuals which interfere with your ability to work?	No	Yes If yes, explain:

E.	DOCTORS/HOSPITALS - From whom/where you have received major medical treatment in the past 2 years:
Name	Address (including zip code)	Phone	Date Last Seen	Nature of Treatment
F.	CURRENT EXAMINATION - Have you had a physical/general medical examination in the past 12 months?

No	Yes If yes, by whom (include address, zip code, and phone number):

G.	FAMILY PHYSICIAN
Name	Address (including zip code)	Phone	Date Last Seen	Nature of Treatment
IV.	SUMMARY - List medical & emotional problem(s) you now have which interfere(s) with your ability to obtain/maintain

employment:	PROBLEM	HOW DOES THE PROBLEM INTERFERE?
V.	This information is true and correct to the best of my knowledge. I have reviewed this information with the counselor and approve the inclusion of this information (including any self-disclosure regarding the results of HIV serology testing or suppressed immune system) in my case file with the Department of Rehabilitation.	VI.	I have reviewed this information with the applicant.

All "YES" answers are explained/clarified on this form or attachments.
Applicant's Signature

	Counselor's Signature


(OVER)

STATE OF CALIFORNIA

Lynda Bates

2009-08-11

RCademarti

Department of Rehabilitation