,canada ,rev5ue ,ag5cy                #a

                           ,t#bbja 7#ji7
                                   #fgbi

          ,4abil;y ,tax ,cr$it
              ,c]tificate
    
  ,? =m is sep>at$ 96two sec;ns3 !
9troduc;n &! =m xf4 ,! 9troduc;n 9cludes
! foll[+3
    --g5]al 9=m,n ab ! 4abil;y am.t2
    --a "qnaire 6help y det]m9e if y may
      2 eligi# =! 4abil;y am.t2
    --def9i;ns2
    --tax (fice a4resses2
    --h[ 6make adju/;t reque/s = previ\s
      ye>s2 &
    --:at 6d if y 4agree ) \r deci.n ab
      yr eligibil;y4
  ,! =m xf 9cludes an applic,n sec;n
7,"p ;,a71 &a c]tific,n sec;n 7,"p ;,b74
,bo? sec;ns (! =m m/ 2 -plet$4

                                      #a
          ,:o uses ? =m--& :y8       a#a
    
  .,9dividuals :o h a sev]e & prol;g$
impair;t 9 physical or m5tal func;ns
7see 8,def9i;ns0 on ! next page71 or _!
repres5tative1 use ,=m ,t#bbja 6apply =!
4abil;y am.t 0-plet+ ,"p ;,a (! =m4
  .,qualifi$ .practi;n]s use ,=m ,t#bbja
6c]tify ! e6ects (! impair;t 0-plet+ ,"p
;,b (! =m4
  ,! 4abil;y am.t is a non-refunda# tax
cr$it us$ 6reduce 9come tax paya# on yr
tax return4 ,? am.t 9cludes a supple;t =
p]sons "u #ah ye>s ( age at ! 5d (! ye>4
,all or "p ( ? am.t may 2 transf]r$ 6yr
sp\se or -mon-law "pn]1 or ano!r
support+ p]son4 ,= m 9=m,n1 g
6_+www.cra.gc.ca/disability_: or get
,guide ,,rc#djfd1 ,m$ical & ,4abil;y-
,relat$ ,9=m,n4
  ,if a * "u #ah ye>s ( age is eligi# =!
4abil;y am.t1 t * is al eligi# =! .,*
.,4abil;y .,b5efit1 an am.t availa# "u !
,canada ,* ,tax ,b5efit4 ,= m 9=m,n1 g
                                      #b
          ,:o uses ? =m--& :y8       b#a
6_+www.cra.gc.ca/benefits_: or get
,pamphlet ,t#daad1 ,canada ,* ,b5efits4
  ,if y qualify =! 4abil;y am.t & y h
"w+ 9come1 y may 2 eligi# =! ..,"w+
,9come ,tax .,b5efit 4abil;y supple;t4
,= m 9=m,n1 g 6_+www.cra.gc.ca/witb_: or
get ,pamphlet ,,rc#dbbg1 ,"w+ ,9come
,tax ,b5efit4

             ,>e y eligi#8
    
  ,y >e eligi# =! 4abil;y am.t only if a
qualifi$ practi;n] c]tifies1 on ? =m1 t
y h a sev]e & prol;g$ impair;t &
c]tifies xs e6ects1 & we approve ! =m4
,6f9d \ if y .may 2 eligi# =! 4abil;y
am.t1 use ! self-assess;t "qnaire on !
next page4
  ,if y rcv ,canada ,p5.n ,plan or
,quebec ,p5.n ,plan 4abil;y b5efits1
"w]s' -p5s,n b5efits1 or o!r types (
4abil;y or 9sur.e b5efits1 ..x does n
necess>ily m1n y >e eligi# =! 4abil;y
.am.t4 ,^! programs h o!r purposes    #c
             ,>e y eligi#8           c#a
& di6]5t crit]ia1 s* z an 9dividual's
9abil;y 6"w4
  ,! ,canada ,rev5ue ,ag5cy m/ validate
? c]tificate = y 6be eligi# =! 4abil;y
am.t4 ,if we h alr told y t y >e eligi#1
d n s5d ano!r =m un.s we ask = "o1 s* z
:5 a previ\s p]iod ( approval has 5d$4
..,h["e1 y m/ tell u if yr 3di;n
.improves4
  ,y c s5d ! =m 6u at any "t dur+ ! ye>4
,0s5d+ u yr =m 2f y file yr tax return1
y may prev5t a delay 9 yr assess;t4 ,we
w review yr applic,n 2f we assess yr
return4 ,keep a copy (! -plet$ =m = yr
records4
  ,fees--,y >e responsi# = any fees t !
qualifi$ practi;n] *>ges 6-plete ? =m or
6give u m 9=m,n4 ,h["e1 y may 2 a#
6claim ^! fees z m$ical exp5ses on l9e
#ccj ( yr tax return4



                                      #d
         ,d y ne$ 9=m,n or =ms8      d#a
    
  ,= 5quiries1 visit \r ,web site at
_+www.cra.gc.ca_: or call
#a-hjj-iei-hbha4 ,if y ne$ =ms or
public,ns1 g 6_+www.cra.gc.ca/forms_: or
call #a-hjj-iei-bbba4
  ,9t]net a3ess--,= 9=m,n1 easy a3ess
6\r =ms & public,ns1 l9ks 6\r gov]n;t
"pn]s1 & 9=m,n ab s]vices = p]sons )
4abilities1 g
6_+www.cra.gc.ca/disability_:4
  ,d y use a teletypewrit] 7,,tty7
op]ator-assi/$ relay s]vice8--,if y use
a ,,tty1 an ag5t at \r bil+ual 5quiry
s]vice 7#a-hjj-ffe-jced7 c help y4
,ag5ts >e availa# ,mon"d 6,fri"d 7except
holi"ds7 f #h3ae a4m4 6#e3jj p4m4 ,f
,febru>y #bb 6,april #cj1 ^! h\rs >e
ext5d$ 6#i3jj p4m4 on week"ds1 & f
#i3jj a4m4 6#e3jj p4m4 on ,satur"ds
7except ,ea/] week5d74
  ,we ne$ yr writt5 p]mis.n 64cuss yr
9=m,n )! ,,tty relay op]ator :5 y 3tact
u "? \r regul> teleph"o 5quiry        #e
         ,d y ne$ 9=m,n or =ms8      e#a
l9es4 ,we ne$ a lr f y giv+ u yr "n1
a4ress & social 9sur.e numb]1 ! "n (!
teleph"o -pany y w use1 yr signature1 &!
date y sign$ ! lr4
  ,if y h a visual impair;t1 y c get \r
public,ns 9 brl1 l>ge pr9t1 etext 7;,,cd
or diskette71 or ,,mp#c 0go+
6_+www.cra.gc.ca/alternate_: or 0call+
#a-hjj-iei-bbba4 ,y c al get yr
p]sonaliz$ correspond;e 9 ^! =mats
0call+ #a-hjj-iei-hbha4
--------------------------------------#b
         ,self-assess;t "qnaire
    
  ,? "qnaire does n replace ! =m xf4 ,x
is provid$ 6help y assess :e!r y may 2
eligi# =! 4abil;y am.t4 ..,d n atta* ?
"qnaire 6! ,=m ,t#bbja y s5d .u4

,note
  ,if yr answ]s 9dicate y .>e .n .eligi#
  =! 4abil;y am.t1 & y / feel t y %d 2
  a# 6claim x1 see page #a (! =m =
  9/ruc;ns on h[ 6apply4              #f
         ,self-assess;t "qnaire      a#b

#a4 ,has yr impair;t 9 physical or m5tal
  func;ns la/$1 or is x expect$ 6la/1 =a
  3t9u\s p]iod ( at l1/ #ab mon?s8
  ,yes ---- ,no ----
  ,if y answ]$ .yes1 answ] ,"qs #b 6#e
    2l4
  ,if y answ]$ .no1 y .>e .n .eligi# =!
    4abil;y am.t4 ,= y 6claim ! 4abil;y
    am.t1 ! impair;t has 6be .prol;g$
    7def9$ on ! next page74
#b4 ,>e y .bl8 ,yes ---- ,no ----
#c4 ,d y rcv .life-su/a9+ .!rapy 7def9$
  2l78 ,yes ---- ,no ----
#d4 ,d ! e6ects ( yr impair;t cause y
  6be .m>k$ly .re/rict$ 7def9$ on ! next
  page7 9 "o (! foll[+ basic activities
  ( daily liv+8 ,yes ---- ,no ----
    --sp1k+
    --he>+
    --walk+
    --elim9,n 7b[el or bla4] func;ns7
    --fe$+
                                      #g
         ,self-assess;t "qnaire      b#b
    --dress+
    --m5tal func;ns nec = "ey"d life
#e4 ,d y meet all ! foll[+ 3di;ns8
  ,yes ---- ,no ----
    --,2c (! impair;t1 y >e
      .significantly .re/rict$ 7def9$ on
      ! next page7 9 two or m (! basic
      activities ( daily liv+ li/$ 9 "q
      #d1 or y >e significantly re/rict$
      9 vi.n & at l1/ "o (! basic
      activities ( daily liv+ li/$ 9 "q
      #d1 ev5 ) appropriate !rapy1
      m$ic,n1 & devices4
    --,^! significant re/ric;ns exi/
      tgr1 all or sub/anti,y all ! "t4
    --,! cumulative e6ect ( ^!
      significant re/ric;ns is equival5t
      62+ .m>k$ly .re/rict$ 7def9$ on !
      next page7 9 a s+le basic activ;y
      ( daily liv+4
    
    

                                      #h
        ,>e y eligi# =! 4abil;y      c#b
                 am.t8
    
  ,if y answ]$ .yes 6,"q #a & 6any "o (
,"qs #b 6#e1 y .may .2 .eligi# =!
4abil;y am.t4 ,6apply =! 4abil;y am.t1
-plete ,"p ;,a (! =m4 ,!n1 take ! =m 6a
qualifi$ practi;n] :o c c]tify ! e6ects
(! impair;t = y4 ,if ! qualifi$
practi;n] c]tifies ! =m1 s5d x 6u =
approval4 ,we w review ! =m & advise y 9
writ+ if y >e eligi# =! 4abil;y am.t4
  ,if y answ]$ .no 6all ( ,"qs #b 6#e1 y
.>e .n .eligi# =! 4abil;y am.t4 ,= y 6be
eligi# =! 4abil;y am.t1 y h 6answ] .yes
6at l1/ "o ( ^! "qs4 ,ev5 if y _c claim
! 4abil;y am.t1 y may h exp5ses y c
claim on yr 9come tax return4 ,= m
9=m,n1 get ,guide ,,rc#djfd1 ,m$ical &
,4abil;y-,relat$ ,9=m,n4

               ,def9i;ns
    
  ,life-su/a9+ !rapy--,life-su/a9+ !rapy
m/ meet ! foll[+ 3di;ns3              #i
               ,def9i;ns             d#b
    --,y rcv ! !rapy 6support a vital
      func;n1 ev5 if x alleviates !
      symptoms4 ,examples ( ? !rapy >e
      *e/ physio!rapy 6facilitate br1?+
      & kidney dialysis 6filt] blood4
      ,h["e1 implant$ devices s* z a
      pacemak]1 or special programs (
      diet1 ex]cise1 or hygi5e .d .n
      qualify4
    --,y h 6d$icate "t = ? !rapy--at l1/
      ..#c "ts a .week1 = an av]age ( at
      l1/ ..#ad h\rs a .week 7d n 9clude
      "t ne$$ 6recup]ate af !rapy1 =
      travel1 m$ical appo9t;ts1 or %opp+
      = m$ic,n74 ,"t d$icat$ 6!rapy m1ns
      t y m/ 2 requir$ 6take "t away f
      normal1 "ey"d activities 9 ord]
      6rcv ! !rapy4 ,! "t x takes =a
      porta# or implant$ device 6deliv]
      !rapy is n 3sid]$ 6be "t d$icat$
      6!rapy4
    

                                     #aj
               ,def9i;ns             e#b
,note
  ,= #bjje & lat] ye>s1 ": ! life-su/a9+
  !rapy requires a regul> dosage (
  m$ic,n t ne$s 6be adju/$ on a daily
  basis3
    --! activities directly relat$
      6det]m9+ ! dosage >e 3sid]$ "p (!
      !rapy1 except = ^? activities
      relat$ 6ex]cise or foll[+ a diet>y
      regime1 s* z c>bohydrate calcul,n2
      &
    --! "t sp5t 0prim>y c>egiv]s p]=m+ &
      sup]vis+ ! activities relat$ 6!
      !rapy (a * 2c ( 8 or h] age is
      3sid]$ 6be "t d$icat$ 6? !rapy4
--------------------------------------#c
  ,m>k$ly re/rict$--,y >e m>k$ly
re/rict$ if1 ..all or sub/anti,y all !
."t1 y >e una# 7or x takes y an 9ord9ate
am.t ( "t7 6p]=m "o or m (! basic
activities ( daily liv+ 7see li/ 9 ,"q
#d on previ\s page71 ev5 ) !rapy 7o!r
?an life-su/a9+ !rapy 6support a vital
                                     #aa
               ,def9i;ns             a#c
func;n7 &! use ( appropriate devices &
m$ic,n4
  ,prol;g$--,an impair;t is prol;g$ if x
has la/$1 or is expect$ 6la/1 =a 3t9u\s
p]iod ( at l1/ #ab mon?s4
  ,qualifi$ practi;n]--,qualifi$
practi;n]s >e m$ical doctors1
optometri/s1 audiologi/s1 o3up,nal
!rapi/s1 physio!rapi/s1 psy*ologi/s1 &
spee*-language pa?ologi/s4 ,! ta# on
page #b (! =m li/s : sec;ns (! =m ea* c
c]tify4
  ,significantly re/rict$--m1ns t al? y
d n .q meet ! crit]ia = m>k$ly re/rict$1
yr abil;y 6p]=m a basic activ;y ( daily
liv+ is / sub/anti,y re/rict$4

          ,": 6s5d ! -plet$ =m
    
  ,s5d ! c]tifi$ =m 6! ..,4abil;y ,tax
,cr$it .,unit ( yr ,tax ,c5tre4 ,see
a4resses 2l4

                                     #ab
          ,": 6s5d ! -plet$ =m       b#c
  ,/4 ,john's ,tax ,c5tre
  ,,po ,box #abjgb ,,/n ;,a
  ,/4 ,john's ,,nl ,a#a;,b #c;,z#b
  
  ,%aw9igan-,sud ,tax ,c5tre
  ,,po ,box #djjj ,,/n ,ma9
  ,%aw9igan ,,qc ,g#i;,n #g;,v#i
  
  ,sudbury ,tax ,c5tre
  #ajej ,notre ,dame ,ave
  ,sudbury ,,on ,p#c;,a #e;,c#a
  
  ,surrey ,tax ,c5tre
  #igee1 ,k+ ,george ,hi<way
  ,surrey ,,bc ,v#c;,t #e;,e#f
  
  ,summ]side ,tax ,c5tre
  #bge ,pope ,road ,summ]side
  ,,pe ,c#a;,n #f;,a#b
  
  ,jonqui@ere ,tax ,c5tre
  #bbea ,r5@e-,l@evesque ,blvd
  ,jonqui@ere ,,qc ,g#g;,s #e;,j#b
                                     #ac
          ,": 6s5d ! -plet$ =m       c#c
  ,w9nipeg ,tax ,c5tre
  ,,po ,box #adjjf ,,/n ,ma9
  ,w9nipeg ,,mb ,r#c;,c #j;,e#e
  
  ,if y >e a deem$ resid5t1 a non-
resid5t1 or a new or return+ resid5t (
,canada1 s5d ! c]tifi$ =m to3

  ,9t]n,nal ,tax ,s]vices ,(fice
  #ajb;,a-#bbjd ,walkley ,rd
  ,ottawa ,,on ,k#a;,a #a;,a#h
  
            ,adju/;t reque/s
    
  ,if y want u 6reassess a tax ye> 6all[
a claim =! 4abil;y am.t1 9clude ,=m
,t#a;,,adj1 ,t#a ,adju/;t ,reque/1 or a
lr 3ta9+ ! details ( yr reque/1 ) yr
-plet$ ,=m ,t#bbja4
  ,if a repres5tative is act+ on yr
2half y m/ provide u )a sign$ lr or ,=m
,t#ajac1 ,au?oriz+ or ,c.ell+ a
,repres5tative1 au?oriz+ ! repres5tative
6make ? reque/4                      #ad
         ,:at if y 4agree ) \r       d#c
                deci.n8
    
  ,if we d n approve yr =m1 we w s5d y a
lr 6expla9 :y yr applic,n 0 d5i$4 ,*eck
yr copy (! =m ag/ ! r1son giv51 s9ce we
base \r deci.n on ! 9=m,n provid$ 0!
qualifi$ practi;n]4
  ,if y h a4i;nal 9=m,n f a qualifi$
practi;n] t we did n h 9 \r f/ review (!
=m1 s5d t 9=m,n 6! ,4abil;y ,tax ,cr$it
,unit ( yr tax c5tre & we w review yr
file ag4
  ,y al h ! "r 6file a =mal objec;n
6app1l ! deci.n4 ,objec;ns1 h["e1 _c 2
bas$ on a lr f u4 ,!y m/ 2 bas$ on a
notice ( assess;t or notice (
reassess;t4 ,we s5d y ^! notices af y
file an 9come tax return or ask =a
correc;n 6an 9come tax return =! ye> 9
"q4
  ,"! is a "t limit = fil+ objec;ns4 ,y
m/ file yr objec;n 0:i*"e (! foll[+
dates -es .lat]3
                                     #ae
            ,:at if y 4agree         e#c
    --"o ye> af ! due date =! return 9
      "q2 or
    --#ij "ds af ! date (! notice (
      assess;t or notice ( reassess;t =
      t ye>4
    
,note
  ,ask+ yr tax c5tre 6review yr file ag
  7see abv7 does n ext5d ! "t limit =
  fil+ an objec;n4

  ,if y *oose 6file a =mal objec;n1 yr
file w 2 review$ 0! ,app1ls ,bran*4 ,y
%d s5d ei a -plet$ ,=m ,t#djj;,a1
,objec;n--,9come ,tax ,act1 or a lr1 6!
att5;n (3

  ,*ief ( ,app1ls
  ,sudbury ,tax ,s]vices ,(fice
  #ajej ,notre ,dame ,av5ue
  ,sudbury ,,on ,p#c;,a #e;,c#a
  

                                     #af
            ,:at if y 4agree         f#c
  ,y may al file an objec;n electronic,y
"? \r secure ,web page at
_+www.cra.gc.ca/myaccount_:4
  ,= m 9=m,n1 visit \r ,web site at
_+www.cra.gc.ca_: or get ,pamphlet
,p#adh1 ,resolv+ ,yr ,4pute3 ,objec;ns &
,app1l ,"rs ,"u ! ,9come ,tax ,act4
















                                     #ag
          ,4abil;y ,tax ,cr$it        #a
              ,c]tificate
    
                                   #fgbi

     ,"p ;,a--,6be -plet$ 0! p]son
            )! 4abil;y 7or a
             repres5tative7
    
  ,/ep #a3 ,-plete ? page 7.pl1se
.pr9t74 ,rememb] 6sign1 ": applica#1 at
! bottom ( ? page4
  ,/ep #b3 ,take ? =m 6a qualifi$
practi;n] 7use ! ta# on ! next page 6f9d
\ :o c c]tify ! sec;ns t apply74
  ,/ep #c3 ,s5d ! -plet$ =m 6"o (!
(fices li/$ 9 8..,": 6s5d ! -plet$ .=m0
9 ! 9troduc;n ( ? =m4 ..,? =m m/ 2
submitt$ 9 xs .5tirety4
  ,:5 review+ yr applic,n1 we may 3tact
y or a qualifi$ practi;n] 7"nd on ?
c]tificate or any atta*$ docu;t7 :o "ks
ab yr impair;t1 if we ne$ m 9=m,n4

                                     #ah
      ,9=m,n ab ! p]son )! 4abil;y   a#a
    
,f/ "n & 9itial ----
,la/ "n ----
,male ---- ,female ----
,mail+ a4ress3 ----
  ,a"p;t ,numb]----
  ,/reet ,numb] ----
  ,/reet "n ----
  ,p4,o4 ,box ----
  ,r4,r4 ----
  ,c;y ----
  ,prov4/t]r4 ----
  ,po/al code ----
,social 9sur.e numb] ----
,date ( bir? 7,ye>/,mon?/,"d7 ----

       ,9=m,n ab ! p]son claim+ !
     4abil;y am.t 7if di6]5t f abv7
    
,f/ "n & 9itial ----
,la/ "n ----
,social 9sur.e numb] ----
,! p]son )! 4abil;y is3
                                     #ai
                ,"p ;,a              b#a
  ---- my sp\se or -mon-law "pn]
  ---- o!r 7specify7 ----
  ,if y >e claim+ ? cr$it =! p]son )!
4abil;y1 answ] ! foll[+ "qs = all ! ye>s
( yr claim4

  #a4 ,does ! p]son )! 4abil;y live ) y8
    ,yes ---- ,no ----
    ,if .yes1 = :at ye>7s78 ----
  #b4 ,if y answ]$ no 6,"q #a1 does !
    p]son )! 4abil;y dep5d on y = "o or
    m (! basic necessities ( life s* z
    food1 %elt]1 or clo?+8
    ,yes ---- ,no ----
    ,if .yes1 = :at ye>7s78 ----
  ,give details ab ! support y provide
=! p]son )! 4abil;y 7if y ne$ m space1
atta* a sep>ate %eet ( pap]73 ----
  ,i c]tify t ! 9=m,n giv5 on ? =m is
correct & -plete4

,sign "h ----
,teleph"o ----
,date ----                           #bj
               ,au?oriz,n            c#a
    
  ,z ! p]son )! 4abil;y or _!
repres5tative1 ,i au?orize ! qualifi$
practi;n]7s7 hav+ relevant cl9ical
records 6provide or 4cuss ! 9=m,n 3ta9$
9 ^? records on or ) ? c]tificate 6!
,canada ,rev5ue ,ag5cy =! purpose (
det]m9+ eligibil;y =! 4abil;y am.t or
o!r relat$ programs4

,sign "h ----
,teleph"o ----
,date ----
--------------------------------------#b
        ,"p ;,b--,6be -plet$ 0!
           qualifi$ practi;n]
    
  ,2f -plet+ ? =m1 r1d ! 9=m,n &!
9/ruc;ns 2l4
  ,yr pati5t m/ h an impair;t 9 physical
or m5tal func;ns : is bo? sev]e &
prol;g$4 ,y m/ assess ! foll[+ two
crit]ia ( yr pati5t's impair;t
.sep>ately3                          #ba
                ,"p ;,b              a#b
  --.,dur,n (! impair;t--,! impair;t m/
    2 prol;g$ 7x m/ h la/$1 or 2 expect$
    6la/1 =a 3t9u\s p]iod ( at l1/ #ab
    mon?s74
  --.,e6ects (! impair;t--,! e6ects ( yr
    pati5t's impair;t m/ 2 ^? :1 ev5 )
    !rapy &! use ( appropriate devices &
    m$ic,n1 cause yr pati5t 6be re/rict$
    all or sub/anti,y all (! "t4 ,!
    e6ects ( yr pati5t's impair;t m/
    fall 96"o (! foll[+ categories3
  --,vi.n
  --,m>k$ly re/rict$ 9 a basic activ;y (
    daily liv+
  --,life-su/a9+ !rapy
  --,! cumulative e6ect ( .significant
    .re/ric;ns 7= pati5ts :o >e
    significantly re/rict$ 9 two or m (!
    basic activities ( daily liv+1
    9clud+ vi.n1 b d n q meet ! crit]ia
    = .m>k$ly .re/rict$7
  ,/ep #a3 ,-plete .only ! sec;ns on
pages #c 6#h t apply 6yr pati5t4 ,ref]
                                     #bb
                ,"p ;,b              b#b
6! ta# 2l 6f9d \ : page7s7 6-plete &
6det]m9e : sec;ns y c c]tify4

,note
  ,:e!r -plet+ ? =m =a * or an adult1
  assess yr pati5t relative 6"s"o (a
  simil> *ronological age :o does n h !
  m>k$ re/ric;n4

,sec;n3 ,vi.n
  ,g to3 ,page #c
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or optometri/ ,m>k$ly
    re/rict$ 9 a basic activ;y ( daily
    liv+
  
,sec;n3 ,sp1k+
  ,g to3 ,page #c
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or spee*-language
    pa?ologi/
  

                                     #bc
                ,"p ;,b              c#b
,sec;n3 ,he>+
  ,g to3 ,page #c
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or audiologi/
  
,sec;n3 ,walk+
  ,g to3 ,page #d
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor1 o3up,nal !rapi/1 or
    physio!rapi/ 7,physio!rapi/ c c]tify
    only = #bjje & lat] ye>s7
  
,sec;n3 ,elim9,n 7b[el or bla4] func;ns7
  ,g to3 ,page #d
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor
  
,sec;n3 ,fe$+
  ,g to3 ,page #e
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or o3up,nal !rapi/
  

                                     #bd
                ,"p ;,b              d#b
,sec;n3 ,dress+
  ,g to3 ,page #e
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or o3up,nal !rapi/
  
,sec;n3 ,p]=m+ ! m5tal func;ns nec =
  "ey"d life
  ,g to3 ,page #f
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or psy*ologi/
  
,sec;n3 ,life-su/a9+ !rapy 6support a
  vital func;n
  ,g to3 ,page #g
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor
  
,sec;n3 ,cumulative e6ects ( significant
  re/ric;ns 7see def9i;n 2l7 9 two or m
  basic activities ( daily liv+1 9clud+
  vi.n 7applies 6#bjje & lat] ye>s7
  ,g to3 ,page #h
  
                                     #be
                ,"p ;,b              e#b
  ,6c]tify ! applica# sec;n1 y h 6be a3
    ,m$ical doctor or o3up,nal !rapi/
    7,o3up,nal !rapi/ c only c]tify =
    walk+1 fe$+ & dress+7
  
  ,/ep #b3 ,-plete ! 8.,e6ects .(
.impair;t10 8.,dur,n10 & 8.,c]tific,n0
sec;ns on page #i4

               ,def9i;ns
    
  ,m>k$ly re/rict$--m1ns t ..all or
sub/anti,y all ! ."t1 & ev5 ) !rapy 7o!r
?an life-su/a9+ !rapy7 &! use ( devices
& m$ic,n1 ei3
    --yr pati5t is una# 6p]=m at l1/ "o
      (! basic activities ( daily liv+
      7see abv72 or
    --x takes yr pati5t an 9ord9ate am.t
      ( "t 6p]=m at l1/ "o (! basic
      activities ( daily liv+4
  ,significantly re/rict$--m1ns t al? yr
pati5t does n q meet ! crit]ia = m>k$ly
re/rict$1 8 or h] abil;y 6p]=m !     #bf
                ,"p ;,b              f#b
basic activ;y ( daily liv+ 7see abv7 or
8 or h] vi.n is / sub/anti,y re/rict$4
--------------------------------------#c
                 ,vi.n
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .bl if1 ev5 )!
use ( corrective l5ses or m$ic,n3
    --visual acu;y 9 .bo? eyes is
      #bj/bjj 7#f/fj7 or less )! ,snell5
      ,*>t 7or an equival5t72 or
    --! grte/ diamet] (! field ( vi.n 9
      .bo? eyes is #bj degrees or less4
  ,is yr pati5t .bl1 z describ$ abv8
    ,yes ---- ,no ----
  ,if .yes1 9 :at ye> did yr pati5t's
    bl;s 2g9 7? is n necess>ily ! same z
    ! ye> 9 : ! diagnosis 0 made1 z )
    progressive 41ses78 ,ye> ----
  ,:at is yr pati5t's visual acu;y .af
    .correc;n8
    ,"r eye ---- ,left eye ----
                                     #bg
                ,"p ;,b              a#c
  ,:at is yr pati5t's visual field .af
    .correc;n 7in degrees if possi#78
    ,"r eye ---- ,left eye ----
  ,-plete all sec;ns on page #i4

                 ,sp1k+
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 sp1k+ if1 all or sub/anti,y all ! "t1
he or %e3
    --is .una# 6sp1k s z 6be "u/ood
      0ano!r p]son famili> )! pati5t1 9
      a quiet sett+1 ev5 ) appropriate
      !rapy1 m$ic,n1 & devices2 or
    --takes an ..9ord9ate am.t ( ."t
      6sp1k s z 6be "u/ood 0a p]son
      famili> )! pati5t1 9 a quiet
      sett+1 ev5 ) appropriate !rapy1
      m$ic,n1 & devices4
    

                                     #bh
                ,"p ;,b              b#c
,notes
  --,devices = sp1k+ 9clude
    tra*eoesophag1l pros!ses1 vocal
    amplific,n devices1 & o!r s*
    devices4
  --,an ..9ord9ate am.t ( ."t m1ns t
    sp1k+ s z 6be "u/ood takes
    .significantly l;g] ?an = an av]age
    p]son :o does n h ! impair;t4
  
  ,examples ( m>k$ly re/rict$ 9 sp1k+
7examples >e n exhau/ive73
    --,yr pati5t m/ rely on o!r m1ns (
      -munic,n1 s* z sign language or a
      symbol bo>d1 all or sub/anti,y all
      ! "t4
    --,in yr (fice1 y m/ ask yr pati5t
      6rep1t ^ws & s5t;es s"eal "ts1 & x
      takes a significant am.t ( "t = yr
      pati5t 6make hmf or h]f "u/ood4
  ,is yr pati5t .m>k$ly .re/rict$ 9
    sp1k+1 z describ$ abv8
    ,yes ---- ,no ----
                                     #bi
                ,"p ;,b              c#c
  ,if .yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 sp1k+ 2g9 7? is n
    necess>ily ! same z ! date (!
    diagnosis1 z ) progressive 41ses78
    ,ye> ----
  ,-plete all sec;ns on page #i4

                 ,he>+
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 he>+ if1 all or sub/anti,y all ! "t1
he or %e3
    --is .una# 6he> s z 6"u/& ano!r
      p]son famili> )! pati5t1 9 a quiet
      sett+1 ev5 )! use ( appropriate
      devices2 or
    --takes an ..9ord9ate am.t ( ."t
      6he> s z 6"u/& ano!r p]son famili>
      )! pati5t1 9 a quiet sett+1 ev5 )!
      use ( appropriate devices4
    
                                     #cj
                 ,he>+               d#c
,notes
  --,devices = he>+ 9clude he>+ aids1
    co*le> implants1 & o!r s* devices4
  --,an ..9ord9ate am.t ( ."t m1ns t
    he>+ s z 6"u/& takes .significantly
    l;g] ?an = an av]age p]son :o does n
    h ! impair;t4
  
  ,examples ( m>k$ly re/rict$ 9 he>+
7examples >e n exhau/ive73
    --,yr pati5t m/ rely -pletely on lip
      r1d+ or sign language1 despite us+
      a he>+ aid1 9 ord] 6"u/& a spok5
      3v]s,n1 all or sub/anti,y all !
      "t4
    --,in yr (fice1 y m/ raise yr voice
      & rep1t ^ws & s5t;es s"eal "ts1 &
      x takes a significant am.t ( "t =
      yr pati5t 6"u/& y1 despite ! use
      (a he>+ aid4
  ,is yr pati5t .m>k$ly .re/rict$ 9
    he>+1 z describ$ abv8
    ,yes ---- ,no ----
                                     #ca
                 ,he>+               e#c
  ,if .yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 he>+ 2g9 7? is n
    necess>ily ! same z ! date (!
    diagnosis1 z ) progressive 41ses78
    ,ye> ----
  ,-plete all sec;ns on page #i4
--------------------------------------#d
                 ,walk+
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 walk+ if1 all or sub/anti,y all ! "t1
he or %e3
    --is .una# 6walk ev5 ) appropriate
      !rapy1 m$ic,n1 & devices2 or
    --requires an ..9ord9ate am.t ( ."t
      6walk1 ev5 ) appropriate !rapy1
      m$ic,n1 & devices4
    
,notes
  --,devices = walk+ 9clude canes1
    walk]s1 & o!r s* devices4
                                     #cb
                ,"p ;,b              a#d
  --,an ..9ord9ate am.t ( ."t m1ns t
    walk+ takes .significantly l;g] ?an
    = an av]age p]son :o does n h !
    impair;t4
  
  ,examples ( m>k$ly re/rict$ 9 walk+
7examples >e n exhau/ive73
    --,yr pati5t m/ alw rely on a
      :eel*air1 ev5 = %ort 4t.es \tside
      (! home4
    --,yr pati5t c walk #ajj metres 7or
      approximately "o c;y block71 b
      only 0tak+ a significant am.t (
      "t1 /opp+ 2c ( %ort;s ( br1? or 2c
      ( pa91 all or sub/anti,y all ! "t4
    --,yr pati5t exp]i;es sev]e episodes
      ( fatigue1 ataxia1 lack (
      coord9,n1 & pro#ms ) bal.e4 ,^!
      episodes cause ! pati5t 6be
      9capacitat$ = s"eal "ds at a "t1 9
      t he or %e 2comes una# 6walk m ?an
      a few /eps4 ,2t episodes1 yr
      pati5t 3t9ues 6exp]i;e ! abv
      symptoms1 b 6a less] degree4   #cc
                ,"p ;,b              b#d
      ,n"e!.s1 ^! less sev]e symptoms
      put yr pati5t at significant risk
      ( 9jury due 6loss ( bal.e1 lack (
      coord9,n1 or fall+1 & cause hm or
      h] 6require an 9ord9ate am.t ( "t
      6walk1 all or sub/anti,y all ! "t4
  ,is yr pati5t .m>k$ly .re/rict$ 9
    walk+1 z describ$ abv8
    ,yes ---- ,no ----
  ,if .yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 walk+ 2g9 7? is n
    necess>ily ! same z ! date (!
    diagnosis1 z ) progressive 41ses78
    ,ye> ----
  ,-plete all sec;ns on page #i4








                                     #cd
        ,elim9,n 7b[el or bla4]      c#d
                func;ns7
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 elim9,n if1 all or sub/anti,y all !
"t1 he or %e3
    --is .una# 6p]son,y manage b[el or
      bla4] func;ns1 ev5 ) appropriate
      !rapy1 m$ic,n1 & devices2 or
    --requires an ..9ord9ate am.t ( ."t
      6p]son,y manage b[el or bla4]
      func;ns1 ev5 ) appropriate !rapy1
      m$ic,n1 & devices4
    
,notes
  --,devices = elim9,n 9clude ca!t]s1
    o/omy appli.es1 & o!r s* devices4
  --,an ..9ord9ate am.t ( ."t m1ns t
    p]son,y manag+ elim9,n takes
    .significantly l;g] ?an = an av]age
    p]son :o does n h ! impair;t4
  ,examples ( m>k$ly re/rict$ 9 elim9,n
7examples >e n exhau/ive73           #ce
                ,"p ;,b              d#d
    --,yr pati5t ne$s ! assi/.e ( ano!r
      p]son 6empty & t5d 6his or h]
      o/omy appli.e on a daily basis4
    --,yr pati5t is 9cont95t ( bla4]
      func;ns1 all or sub/anti,y all !
      "t1 & requires an 9ord9ate am.t (
      "t 6manage & t5d 6his or h]
      9cont9;e pads on a daily basis4
  ,is yr pati5t m>k$ly re/rict$ 9
    elim9,n1 z describ$ abv8
    ,yes ---- ,no ----
  ,if yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 elim9,n 2g9 7? is n
    necess>ily ! same z ! date (!
    diagnosis1 z ) progressive 41ses78
    ,ye> ----
  






                                     #cf
                 ,fe$+                #e
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 fe$+ if1 all or sub/anti,y all ! "t1
he or %e3
    --is .una# 6fe$ hmf or h]f1 ev5 )
      appropriate !rapy1 m$ic,n1 &
      devices2 or
    --requires an ..9ord9ate am.t ( ."t
      6fe$ hmf or h]f1 ev5 ) appropriate
      !rapy1 m$ic,n1 & devices4
    
,notes
  --,fe$+ "of .does .n 9clude id5tify+1
    f9d+1 %opp+ = or o!rwise procur+
    food4
  --,fe$+ "of .does 9clude prep>+ food1
    .except :5 ! "t associat$ is relat$
    6a diet>y re/ric;n or regime1 ev5 :5
    ! re/ric;n or regime is requir$ due
    6an ill;s or h1l? 3di;n4
  --,devices = fe$+ 9clude modifi$
    ut5sils1 & o!r s* devices4       #cg
                ,"p ;,b              a#e
  --,an ..9ord9ate am.t ( ."t m1ns t
    fe$+ takes .significantly l;g] ?an =
    an av]age p]son :o does n h !
    impair;t4
  ,examples ( m>k$ly re/rict$ 9 fe$+
7examples >e n exhau/ive73
    --,yr pati5t requires tube fe$+s1
      all or sub/anti,y all ! "t1 =
      nutri;nal su/5.e4
    --,yr pati5t requires an 9ord9ate
      am.t ( "t 6prep>e m1ls or 6fe$ hmf
      or h]f1 on a daily basis1 due
      6significant pa9 & decr1s$ /r5g? &
      dext];y 9 ! upp] limbs4
  ,is yr pati5t .m>k$ly .re/rict$ 9
    fe$+1 z describ$ abv8
    ,yes ---- ,no ----
  ,if .yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 fe$+ 2g9 7? is n
    necess>ily ! same z ! date (!
    diagnosis1 z ) progressive 41ses78
    ,ye> ----
  ,-plete all sec;ns on page #i4
                                     #ch
                ,dress+              b#e
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 dress+ if1 all or sub/anti,y all ! "t1
he or %e3
    --is .una# 6dress hmf or h]f1 ev5 )
      appropriate !rapy1 m$ic,n1 &
      devices2 or
    --requires an ..9ord9ate am.t ( ."t
      6dress hmf or h]f1 ev5 )
      appropriate !rapy1 m$ic,n1 &
      devices4
    
,notes
  --,dress+ "of .does .n 9clude
    id5tify+1 f9d+1 %opp+ = or o!rwise
    procur+ clo?+4
  --,devices = dress+ 9clude specializ$
    buttonhooks1 l;g-h&l$ %oehorns1 grab
    rails1 safety pulls1 & o!r s*
    devices4
  --,an 9ord9ate am.t ( "t m1ns t dress+
    takes significantly l;g] ?an =   #ci
                ,"p ;,b              c#e
    an av]age p]son :o does n h !
    impair;t4
  ,examples ( m>k$ly re/rict$ 9 dress+
7examples >e n exhau/ive73
    --,yr pati5t _c dress )\t daily
      assi/.e f ano!r p]son4
    --,due 6pa91 /i6;s1 & decr1s$
      dext];y1 yr pati5t requires an
      9ord9ate am.t ( "t 6dress on a
      daily basis4
  ,is yr pati5t m>k$ly re/rict$ 9
    dress+1 z describ$ abv8
    ,yes ---- ,no ----
  ,if .yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 dress+ 2g9 7? is n
    necess>ily ! same z ! date (!
    diagnosis1 z ) progressive 41ses78
    ,ye> ----
  ,-plete all sec;ns on page #i4




                                     #dj
       ,m5tal func;ns nec = "ey"d     #f
                  life
    
                        ,n applica# ----

  ,yr pati5t is 3sid]$ .m>k$ly .re/rict$
9 p]=m+ ! m5tal func;ns nec = "ey"d life
7describ$ 2l7 if1 all or sub/anti,y all
! "t1 he or %e3
    --is .una# 6p]=m !m 0hmf or h]f1 ev5
      ) appropriate !rapy1 m$ic,n1 &
      devices 7= example1 memory aids &
      adaptive aids72 or
    --requires an ..9ord9ate am.t ( ."t
      6p]=m !m 0hmf or h]f1 ev5 )
      appropriate !rapy1 m$ic,n1 &
      devices4 ,an 9ord9ate am.t ( "t
      m1ns t yr pati5t takes
      .significantly l;g] ?an an av]age
      p]son :o does n h ! impair;t4
    
  ,m5tal func;ns nec = "ey"d life
9clude3
    --,adaptive func;n+ 7= example1
      abilities relat$ 6self-c>e1    #da
                ,"p ;,b              a#f
      h1l? & safety1 social skills &
      -mon1 simple transac;ns72
    --,memory 7= example1 ! abil;y
      6rememb] simple 9/ruc;ns1 basic
      p]sonal 9=m,n s* z "n & a4ress1 or
      mat]ial ( import.e & 9t]e/72 &
    --,pro#m-solv+1 goal-sett+1 &
      judge;t1 tak5 tgr 7= example1 !
      abil;y 6solve pro#ms1 set & keep
      goals1 .& make appropriate deci.ns
      & judge;ts74
    
      ,important--a re/ric;n 9
      pro#m-solv+1 goal-sett+1 or
      judge;t t m>k$ly re/ricts adaptive
      func;n+1 all or sub/anti,y all !
      "t1 wd qualify4
  ,examples ( m>k$ly re/rict$ 9 ! m5tal
func;ns nec = "ey"d life 7examples >e n
exhau/ive73
    --,yr pati5t is una# 6l1ve ! h\se1
      all or sub/anti,y all ! "t1 due
      6anxiety1 despite m$ic,n & !rapy4
                                     #db
                ,"p ;,b              b#f
    --,yr pati5t is 9dep5d5t 9 "s
      aspects ( "ey"d liv+4 ,h["e1
      despite m$ic,n & !rapy1 yr pati5t
      ne$s daily support & sup]vi.n due
      6an 9abil;y 6a3urately 9t]pret 8
      or h] 5viron;t4
    --,yr pati5t is 9capa# ( mak+ a
      -mon1 simple transac;n )\t
      assi/.e1 all or sub/anti,y all !
      "t4
    --,yr pati5t exp]i;es psy*otic
      episodes s"eal "ts a ye>4 ,giv5 !
      unpredictabil;y (! psy*otic
      episodes &! o!r def9+ symptoms ( 8
      or h] impair;t 7= example1
      avoli;n1 4organiz$ 2havi\r &
      spee*71 yr pati5t 3t9ues 6require
      .daily sup]vi.n4
    --,yr f\r-ye>-old pati5t _c play
      9t]actively ) pe]s or "u/& simple
      reque/s4
  ,is yr pati5t .m>k$ly .re/rict$ 9
    p]=m+ ! m5tal func;ns nec = "ey"d
                                     #dc
                ,"p ;,b              c#f
    life1 z describ$ abv8
    ,yes ---- ,no ----
  ,if .yes1 :5 did yr pati5t's m>k$
    re/ric;n 9 ! m5tal func;ns nec =
    "ey"d life 2g9 7? is n necess>ily !
    same z ! date (! diagnosis1 z )
    progressive 41ses78 ,ye> ----
  ,-plete all sec;ns on page #i4
--------------------------------------#g
           ,life-su/a9+ !rapy
    
                        ,n applica# ----

  ,yr pati5t ne$s life-su/a9+ !rapy
6support a vital func;n1 ev5 if ! !rapy
has alleviat$ ! symptoms4 ,yr pati5t
ne$s ! !rapy at l1/ #c "ts p] week1 = an
av]age ( at l1/ #ad h\rs p] week4

,notes
  ,! foll[+ po9ts apply 9 det]m9+ ! "t
  yr pati5t sp5ds on !rapy3
    --,yr pati5t m/ d$icate ! "t =!
      !rapy--t is1 ! pati5t has      #dd
                ,"p ;,b              a#g
      6take "t away f normal1 "ey"d
      activities 6rcv x4 ,if yr pati5t
      rcvs !rapy 0a porta# device1 s* z
      an 9sul9 pump1 or an implant$
      device1 s* z a pacemak]1 ! "t !
      device takes 6deliv] ! !rapy .does
      .n c.t t[>ds ! #ad-h\r require;t4
      ,h["e1 ! "t yr pati5t sp5ds sett+
      up a porta# device .does c.t4
    --.,d .n .9clude activities s* z
      foll[+ a diet>y re/ric;n or
      regime1 ex]cis+1 travell+ 6rcv !
      !rapy1 att5d+ m$ical appo9t;ts
      7o!r ?an appo9t;ts ": ! !rapy is
      rcvd71 %opp+ = m$ic,n1 or
      recup]at+ af !rapy4
    
          ,= #bjje & lat] ye>s
    
  --,if yr pati5t's !rapy requires a
    regul> dosage ( m$ic,n t ne$s 6be
    adju/$ daily1 ! activities directly
    relat$ 6det]m9+ & adm9i/]+ ! dosage
    .>e 3sid]$ "p (! !rapy 7=        #de
                ,"p ;,b              b#g
    example1 monitor+ blood glucose
    levels1 prep>+ & adm9i/]+ ! 9sul91
    calibrat+ nec equip;t1 or ma9ta9+ a
    logbook ( blood glucose levels74
  --,activities t >e 3sid]$ 6be "p (
    foll[+ a diet>y regime1 s* z
    c>bohydrate calcul,n1 z well z
    activities relat$ 6ex]cise1 .d .n
    .c.t t[>d ! #ad-h\r require;t 7ev5
    :5 ^! activities or regimes >e a
    factor 9 det]m9+ ! daily dosage (
    m$ic,n74
  --,if a * is una# 6p]=m ! activities
    relat$ 6! !rapy 2c ( 8 or h] age1 !
    "t sp5t 0! *'s prim>y c>egiv]s p]=m+
    & sup]vis+ ^! activities .c 2 c.t$
    t[>d ! #ad-h\rrequire;t4 ,= example1
    9 ! case (a * ) ,type #a diabetes1
    sup]vi.n 9cludes hav+ 6wake ! * at
    ni<t 6te/ 8 or h] blood glucose
    level1 *eck+ ! * 6det]m9e ! ne$ =
    a4i;nal blood glucose te/+ 7dur+ or
    af physical activ;y71 or o!r
    sup]visory activities t c        #df
                ,"p ;,b              c#g
    r1sonably 2 3sid]$ nec 6adju/ !
    dosage ( 9sul9 7exclud+ c>bohydrate
    calcul,n74
  ,examples ( life-su/a9+ !rapy
7examples >e n exhau/ive73
    --,*e/ physio!rapy 6facilitate br1?+
    --,kidney dialysis 6filt] blood
    --,9sul9 !rapy 6tr1t ,type #a
      diabetes 9 a * :o _c 9dep5d5tly
      adju/ ! 9sul9 dosage 7= #bjje &
      lat] ye>s7
  ,does yr pati5t meet ! 3di;ns =
    .life-su/a9+ .!rapy1 z describ$ abv8
    ,yes ---- ,no ----
  ,if .yes1 :5 did yr pati5t's !rapy 2g9
    6meet ! 3di;ns 7? is n necess>ily !
    same z ! date (! diagnosis1 z )
    progressive 41ses78 ,ye> ----
  ,pl1se provide details (! !rapy 7=
    example dialysis1 or = p]sons )
    diabetes1 9sul9 pump or multiple
    daily 9jec;ns73 ----
  ,-plete all sec;ns on page #i4
                                     #dg
          ,cumulative e6ect (         #h
     significant re/ric;ns--applies
           6#bjje & lat] ye>s
    
                        ,n applica# ----

  ,if yr pati5t is m>k$ly re/rict$ "u
any (! previ\s sec;ns1 x is n nec
6-plete ? sec;n4
  ,answ] ! "qs 9 ! foll[+ *eckli/ 6help
y det]m9e if yr pati5t qualifies =!
4abil;y am.t4
  ,rememb] 6answ] ! "qs at ! bottom ( ?
page4

  #a4 ,does yr pati5t h at l1/ "o
    impair;t 9 physical or m5tal func;ns
    t has la/$1 or is expect$ 6la/1 =a
    3t9u\s p]iod ( at l1/ #ab mon?s8
    ,yes ---- ,no ----
  #b4 ,ev5 ) appropriate !rapy1 m$ic,n1
    & devices1 has ! impair;t result$ 9
    a .significant .re/ric;n1 t is n q a
    .m>k$ .re/ric;n 7def9$ 2l71 9 two or
                                     #dh
                ,"p ;,b              a#h
    m basic activities ( daily liv+8
    ,yes ---- ,no ----
  #c4 ,d ^! significant re/ric;ns exi/
    tgr1 all or sub/anti,y all ! "t8
    ,yes ---- ,no ----
  #d4 ,is ! cumulative e6ect ( ^!
    significant re/ric;ns equival5t 6a
    m>k$ re/ric;n 9 a s+le basic activ;y
    ( daily liv+ 7see examples 2l78
    ,yes ---- ,no ----
  
,notes
  --,y .c 9clude vi.n 9 -b9,n )! basic
    activities ( daily liv+4
  --,y ._c 9clude ! "t sp5t on
    life-su/a9+ !rapy4
  
               ,def9i;ns
    
  .,m>k$ly .re/rict$ m1ns t ..all or
sub/anti,y all ! ."t1 & ev5 ) !rapy 7o!r
?an life-su/a9+ !rapy7 &! use ( devices
& m$ic,n1 ei3
                                     #di
                ,"p ;,b              b#h
    --yr pati5t is una# 6p]=m at l1/ "o
      (! basic activities ( daily liv+2
      or
    --x takes yr pati5t an 9ord9ate am.t
      ( "t 6p]=m at l1/ "o (! basic
      activities ( daily liv+4
  ,significantly re/rict$ m1ns t al? yr
pati5t does n .q meet ! crit]ia = m>k$ly
re/rict$1 8 or h] abil;y 6p]=m ! basic
activ;y ( daily liv+ or vi.n is /
sub/anti,y re/rict$4
  ,examples ( cumulative e6ects
equival5t 62+ m>k$ly re/rict$ 9 a basic
activ;y ( daily liv+ 7examples >e n
exhau/ive73
    --,yr pati5t c walk = #ajj metres1 b
      !n m/ take "t 6recup]ate4 ,he or
      %e c p]=m ! m5tal func;ns nec =
      "ey"d life1 b c 3c5trate on any
      topic = only a %ort p]iod ( "t4 ,!
      cumulative e6ect ( ^! two
      significant re/ric;ns is equival5t
      62+ m>k$ly re/rict$1 s* z 2+ una#
                                     #ej
                ,"p ;,b              c#h
      6p]=m "o (! basic activities (
      daily liv+4
    --,yr pati5t alw takes a l;g "t =
      walk+1 dress+ & fe$+4 ,! extra "t
      x takes 6p]=m ^! activities1 :5
      a4$ tgr1 is equival5t 62+ m>k$ly
      re/rict$1 s* z tak+ an 9ord9ate
      am.t ( "t 9 a s+le basic activ;y (
      daily liv+4
  ,answ] ! foll[+ "q7s7 6c]tify yr
    pati5t's 3di;n3
  ,d y c]tify t yr pati5t meets ! f\r
    3di;ns describ$ 9 ! *eckli/ abv8
    ,yes ---- ,no ----
  ,if .yes1 tick at l1/ two (! foll[+1 z
    !y apply 6yr pati5t4
    ---- vi.n
    ---- sp1k+
    ---- he>+
    ---- walk+
    ---- elim9,n 7b[el or bla4] func;ns7
    ---- fe$+
    
                                     #ea
                ,"p ;,b              d#h
    ---- dress+
    ---- m5tal func;ns nec = "ey"d life
  ,if .yes1 :5 did ! cumulative e6ect
    describ$ abv 2g9 7? is n necess>ily
    ! same z ! date (! diagnosis1 z )
    progressive 41ses78 ,ye> ----
  ,-plete all sec;ns on page #i4
--------------------------------------#i
           ,e6ects ( impair;t
    
  ,! e6ects ( yr pati5t's impair;t m/ 2
^? :1 ev5 ) !rapy &! use ( appropriate
devices & m$ic,n1 cause yr pati5t 6be
re/rict$ ..all or sub/anti,y all (! ."t4

,notes
  --,basic activities ( daily liv+ >e
    limit$ 6walk+1 sp1k+1 he>+1 dress+1
    fe$+1 elim9,n1 & m5tal func;ns nec =
    "ey"d life4
  --,"w+1 h\sekeep+1 & social or
    recre,nal activities >e n 3sid]$
    basic activities ( daily liv+4
                                     #eb
                ,"p ;,b              a#i
  ,examples ( e6ects ( impair;t
7examples >e n exhau/ive73
    --,=a pati5t )a walk+ impair;t1 y
      mi<t /ate ! numb] ( h\rs sp5t 9 b$
      or 9 a :eel*air ea* "d4
    --,=a pati5t ) an impair;t 9 m5tal
      func;ns nec = "ey"d life1 y mi<t
      describe ! degree 6: yr pati5t
      ne$s support & sup]vi.n4
  ,describe ! e6ects ( yr pati5t's
impair;t7s7 on 8 or h] abil;y 6p]=m ea*
(! basic activities ( daily liv+ t y
9dicat$ >e or 7 m>k$ly or significantly
re/rict$ 79clude ! diagnosis1 if
availa#74 ,if y ne$ m space 2l1 atta* a
sep>ate %eet ( pap]4
,diagnosis3 ----
,e6ects ( impair;t3 ----

                 ,dur,n
    
  ,has yr pati5t's impair;t la/$1 or is
x expect$ 6la/1 =a 3t9u\s p]iod ( at l1/
#ab mon?s8 ,= dec1s$ pati5ts1 0 !    #ec
                ,"p ;,b              b#i
impair;t expect$ 6la/ =a 3t9u\s p]iod (
at l1/ #ab mon?s8 ,yes ---- ,no ----
  ,if .yes1 has ! impair;t improv$1 or
is x likely 6improve1 s* t ! pati5t wd
no l;g] 2 bl1 m>k$ly re/rict$1 equival5t
6m>k$ly re/rict$ due 6! cumulative e6ect
( significant re/ric;ns1 or 9 ne$ (
life-su/a9+ !rapy8
  ,yes ----
  ,no ----
  ,unsure ----

  ,if .yes1 /ate ! ye> t ! improve;t
o3ur$ or may 2 expect$ 6o3ur ----

               ,c]tific,n
    
  ,tick ! box t applies 6y3
    ---- ,m$ical doctor
    ---- ,optometri/
    ---- ,o3up,nal !rapi/
    ---- ,audiologi/
    ---- ,physio!rapi/
                                     #ed
                ,"p ;,b              c#i
    ---- ,psy*ologi/
    ---- ,spee*-language pa?ologi/
  ,z a .qualifi$ .practi;n]1 ,i c]tify
t1 6! be/ ( my k1 ! 9=m,n giv5 9 ,"p ;,b
( ? =m is correct & -plete & ,i "u/& t ?
9=m,n w 2 us$ 0! ,,cra 6det]m9e if my
pati5t is eligi# =! 4abil;y am.t or o!r
relat$ programs4

,sign "h ----
,pr9t yr "n ----
,date ----
,teleph"o ----
,a4ress ----

,note
  ,if fur!r 9=m,n or cl>ific,n is ne$$1
  ! ,,cra may 3tact y4





                                     #ee