VA Form 10-10M, the Medical Certificate, is a one-page form that a VA clinician fills out during a clinical encounter to record how you arrived, your vital signs, the exam findings, a diagnosis, a treatment plan, and your discharge instructions. Your part is small: provide identifying information and medication and allergy details at check-in, then sign the discharge section at the end to confirm you received and understood your aftercare instructions. You can download a blank copy from va.gov/forms/10-10m/, but staff will usually have the form ready when you arrive.
What the Form Records
The Medical Certificate has two sections on the front page and a continuation area on the back. Section I documents the visit itself: arrival status, vital signs, medical history, physical examination, diagnostic impressions, and the treatment plan. Section II covers what happens when the visit ends: your disposition (home, admitted, or referred), aftercare instructions, activity limitations, condition at discharge, and your signed acknowledgment.
Page two provides continuation space for tracking vital signs over time, recording physician orders, listing studies and results, and adding progress notes. For longer or more complex encounters, the clinician uses that page to keep a running record without starting a separate document.
Section I: What You Provide at Intake
Almost all of Section I is completed by clinical staff, but a few fields depend on what you tell them or confirm at check-in. The form itself is short. Field-by-field, here is what goes in each slot:
- Patient identification: staff imprint your VA health identification card into a designated area, so your name and ID number don’t have to be written by hand.
- Fields 1–2, date and time: when the encounter begins, including AM or PM.
- Fields 3–4, age and sex: basic demographics from your record or confirmed at intake.
- Field 5, arrival mode: a checkbox for wheelchair, stretcher, or ambulatory. This documents your physical status on arrival.
- Field 6, phone number: your current contact number.
- Field 7, homeless status: a yes/no checkbox. A “yes” can trigger referrals to VA housing and social work programs.
- Fields 8A–8F, vital signs: allergies, weight, temperature, pulse, respiration rate, and blood pressure, recorded by the nurse or clinician.
- Field 8G, injury indicator: whether the visit is due to an injury.
- Field 9, current medications: what you’re taking now. Bring a written list with dosages or bring your bottles.
- Field 10, triage: the triage nurse’s assessment of urgency and initial observations.
- Field 11, examiner’s signature: signed by the clinician doing the initial assessment.
- Field 12, history and physical: the examiner’s narrative on your symptoms, relevant history, and exam findings.
- Field 13, diagnostic impressions: the working diagnosis or diagnoses.
- Field 14, plan: medications prescribed, procedures ordered, tests requested, and referrals.
- Fields 15A–15B, attending of record and examiner’s signature: identifies who is responsible for your care during the visit.
The most useful thing you can do to help the clinician complete Section I accurately is arrive with a current medication list including dosages, know your allergy history, and be ready to describe your symptoms and how they started. If you use a wheelchair or arrived by ambulance, make sure the arrival-mode checkbox in Field 5 reflects that. It creates a record that can matter later.
Section II: What You Sign at Discharge
Section II shifts from what happened during the visit to what you need to do afterward. The clinician fills in the medical details; you sign at the bottom to confirm you received the instructions.
- Field 1, disposition or clinic appointment: where you’re going next — home, admitted, or scheduled for follow-up.
- Field 2, aftercare sheet given: a yes/no checkbox confirming you received written instructions.
- Field 3, follow-up, activity, and limitations: restrictions on physical activity, work, or daily tasks, plus when and where to follow up.
- Field 4, condition at discharge: improved, unchanged, or satisfactory.
- Field 5, date and time of discharge: when you were released.
- Field 6, clinician’s signature: the provider signs to indicate instructions were given.
- Field 7, patient instructions: written details on wound care, medication changes, warning signs, or other specific guidance.
- Field 8, patient’s signature: you sign to certify you received and understand the discharge instructions.
Read Field 3 carefully before you sign. If a restriction or instruction isn’t clear, ask before you leave. Once you walk out, getting clarification usually means calling back or waiting on a secure message. Keep your copy of the aftercare sheet. It’s your reference for medication changes and follow-up dates.
Where to Get the Form
The blank PDF is available on the VA forms page at va.gov/forms/10-10m/. In practice you won’t need to bring a blank copy. VA clinical staff will have the form on hand and start it when you check in. The form was last revised in December 2016.
Why the Arrival-Mode Checkbox Matters Beyond the Visit
The arrival-mode field in Section I (wheelchair, stretcher, or ambulatory) creates a clinical record of how you traveled to your appointment. That documentation can become relevant when you file for travel reimbursement under the VA’s Beneficiary Travel program, which is authorized by 38 U.S.C. § 111 and covers eligible veterans for the cost of getting to and from VA healthcare appointments.
If a clinician determines during your encounter that you need specialized transport, such as an ambulance or a wheelchair-accessible van, for future appointments, raise it during the visit so the medical necessity can be documented while you’re being examined. The clinical findings on Form 10-10M — the arrival mode, physical exam, and diagnostic impressions — can support special mode transportation requests. Retrofitting that documentation after the fact is harder and slower.
What Happens to the Form After You Sign
Once the clinician finishes Section I and you sign Section II, the form becomes part of your VA medical record. Future providers at any VA facility can review the diagnostic impressions, treatment plan, and follow-up instructions from the encounter. If the visit results in a referral, the notes in Fields 13 and 14 guide the specialist who sees you next. For travel purposes, the documented arrival mode and clinical findings stay in your file and can be referenced when a Beneficiary Travel claim is processed.