Applicant Medical History Form Page 2
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1
2
3PLEASE CIRCLE ALL THAT APPLY:
This effects of this patient's disability include:
Deafness Speech impairment Reduced stamina Hearing loss
Coordination problems Limited mobility
Memory loss Spasticity
Delayed development
Vision impairment
Muscular weakness
Other:________________________________________________
_
Does this patient have trouble with...
Allergies
Chronic pain
Heightened emotions
Depression
Seizures
Balance
Brittle bones
Heat/Cold Sensitivity
Does this patient use any of the following aids or assistive devices?
Prosthesis
Leg brace
Wheelchair- manual
Wheelchair- electric
Wrist brace
Hearing aid
Crutch/cane
Walker
Other:_____________________________________________
_______
Does this patient...
Drive
Travel by bus
Travel by airplane
Current number of hours of attendant care per week:_______________ ______________
ADL= Activities of Daily Living
Is this patient:
Please Circle Below
A. Able to exercise judgment and make
decisions necessary for ADL?
Yes Minimally No
B. Able to sustain an attention span?
Yes Minimally No
C. Manifesting inappropriate behavior beyond
his or her control?
Yes Minimally No
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