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HICN 6. ONSET DATE 7. SOC DATE 04/14/06 02/25/06 9. PRIMARY DIAGNOSIS Pert. Med. DX 2. PROVIDER NO. 21. FUNCTIONAL LEVEL End of billing period See Page 2 FORM CMS Formerly HCFA - 700 01/02 PROGRESS REPORT 22. Motor Skills - Right Objects Difficult to Handle Computer mouse Grooming devices Pen or pencil Gross Coordination Appears WNL Fine Coordination Impaired Crossing the Midline Appears WNL Bilateral Integration Appears WNL Praxis Appears WNL Dexterity Appears WNL Visual Motor Appears WNL...
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