TX HHS Form 3104. General Physical Examination Report

The TX HHS Form 3104, General Physical Examination Report, is a crucial document used to determine eligibility for rehabilitation services or develop a plan for an individual's rehabilitation. This form helps solve the problem of assessing an individual's physical condition and identifying any reported disabilities.

This report requires essential information such as patient details, including name, date of birth, social security number, and telephone number. The form also asks for the reason for referral and a condensed medical history, which includes descriptions of any abnormalities and blood pressure readings. Additionally, the report requests vision testing results using the Snellen chart, with or without glasses.

The TX HHS Form 3104 is typically used when an individual seeks rehabilitation services from the Texas Division for Rehabilitation Services (DRS). This form helps counselors determine the best course of action for the individual's rehabilitation and provides a comprehensive overview of their physical condition.