VA Form 10-10M "Medical Certificate"

What Is VA Form 10-10M?

This is a legal form that was released by the U.S. Department of Veterans Affairs on December 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2016;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of VA Form 10-10M by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 10-10M "Medical Certificate"

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CONTINUE ON BACK WHEN NECESSARY
MEDICAL CERTIFICATE
AM
1. DATE
2. TIME
3. AGE
4. SEX
5.ON ARRIVAL PATIENT WAS:
6. PHONE NUMBER
7. HOMELESS
PM
M
F
AMBULATORY
STRETCHER
WHEELCHAIR
YES
NO
8A. ALLERGIES
8B. WEIGHT
8C. TEMPERATURE
8D. PULSE
8E. RESPIRATION
8F.B/P
8G. DUE TO INJURY
NO
YES
9. CURRENT MEDICATIONS
10. TRIAGE
11. SIGNATURE
12. HISTORY AND PHYSICAL
13. DIAGNOSTIC IMPRESSIONS
14. PLAN
15A. ATTENDING OF RECORD
15B. EXAMINER’S SIGNATURE
SECTION II - FOR PATIENT
1. DISPOSITION/CLINIC APPOINTMENT
2. AFTER CARE SHEET GIVEN
3. FOLLOW UP - ACTIVITY - LIMITATIONS
YES
NO
4. CONDITION
5. DATE/TIME OF DISCHARGE
6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED
SATISFACTORY
UNCHANGED
IMPRINT PATIENT DATA CARD
7. PATIENT INSTRUCTIONS
I CERTIFY THAT I RECEIVED AND
8. PATIENT’S SIGNATURE
UNDERSTAND THESE INSTRUCTIONS
VA FORM
10-10M
DEC 2016
SUPERSEDES VA FORM10-10M, MAY1990, WHICH WILL NOT BE USED.
CONTINUE ON BACK WHEN NECESSARY
MEDICAL CERTIFICATE
AM
1. DATE
2. TIME
3. AGE
4. SEX
5.ON ARRIVAL PATIENT WAS:
6. PHONE NUMBER
7. HOMELESS
PM
M
F
AMBULATORY
STRETCHER
WHEELCHAIR
YES
NO
8A. ALLERGIES
8B. WEIGHT
8C. TEMPERATURE
8D. PULSE
8E. RESPIRATION
8F.B/P
8G. DUE TO INJURY
NO
YES
9. CURRENT MEDICATIONS
10. TRIAGE
11. SIGNATURE
12. HISTORY AND PHYSICAL
13. DIAGNOSTIC IMPRESSIONS
14. PLAN
15A. ATTENDING OF RECORD
15B. EXAMINER’S SIGNATURE
SECTION II - FOR PATIENT
1. DISPOSITION/CLINIC APPOINTMENT
2. AFTER CARE SHEET GIVEN
3. FOLLOW UP - ACTIVITY - LIMITATIONS
YES
NO
4. CONDITION
5. DATE/TIME OF DISCHARGE
6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED
SATISFACTORY
UNCHANGED
IMPRINT PATIENT DATA CARD
7. PATIENT INSTRUCTIONS
I CERTIFY THAT I RECEIVED AND
8. PATIENT’S SIGNATURE
UNDERSTAND THESE INSTRUCTIONS
VA FORM
10-10M
DEC 2016
SUPERSEDES VA FORM10-10M, MAY1990, WHICH WILL NOT BE USED.
VITAL SIGNS
MD
NURSE
TIME
TIME
ORDERS
TIME
EFFECTIVENESS
SIGNATURE
SIGNATURE
TEMP
PULSE
RESP
B/P
CONTINUATION FROM FRONT/PROGRESS NOTE
STUDIES REQUESTED
RESULTS
VA FORM
10-10M
PAGE 2
DEC 2016
SECTION II - FOR PATIENT
1. DISPOSITION/CLINIC APPOINTMENT
2. AFTER CARE SHEET GIVEN
3. FOLLOW UP-ACTIVITY-LIMITATIONS
YES
NO
4. CONDITION
5. DATE/TIME OF DISCHARGE
6. SIGNATURE TO INDICATE INSTRUCTIONS GIVEN
IMPROVED
SATISFACTORY
UNCHANGED
7. PATIENT INSTRUCTIONS
IMPRINT PATIENT DATA CARD
I CERTIFY THAT I RECEIVED AND
8. PATIENT’S SIGNATURE
UNDERSTAND THESE INSTRUCTIONS
VA FORM
10-10M
PATIENTS COPY
PAGE 3
MAR 1992
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