Disability Allowance Form Page 33
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Part 12 continued
Medical report by your doctor
A
/D
P
:
BILITY
ISABILITY
ROFILE
10.Indicate the degree to which your patient's condition has affected their ability in ALL of the
following areas.
Normal
Mild
Moderate
Severe
Profound
Mental Health/Behaviour
Learning/Intelligence
Consciousness/Seizures
Balance/Co-ordination
Vision
Hearing
Speech
Continence
Reaching
Manual Dexterity
Lifting/Carrying
Bending/Kneeling/Squatting
Sitting/Rising
Standing
Climbing Stairs/Ladders
Walking
11.A Medical Assessment by one of the Department’s Medical Assessors may be required to
determine eligibility.
Yes
No
Is your patient fit to attend a medical assessment?
If ‘No’, give details here:
12.Is the customer suitable for work/training for rehabilitative purposes?
Yes
No
This section is only relevant to Companion Free Travel Pass applications
13.Does the patient use a wheelchair for mobility, on a permanent basis?
9023418265
9023418265
9023418265
9023418265
Yes
No
14.Is the patient registered with the National Council for the Blind or National League of the
Blind of Ireland?
Yes
No
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86E9C4FB
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