Disability Tax Credit Certificate - Canada Revenue Agency Page 3
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Patient's name:
Eliminating
(bowel or bladder functions) – Medical doctor or nurse practitioner
(under proposed changes)
Your patient is considered markedly restricted in eliminating if, even with appropriate therapy, medication, and devices:
• he or she is unable or takes an inordinate amount of time to personally manage bowel or bladder functions; and
• this is the case all or substantially all of the time (at least 90% of the time).
Is your patient markedly restricted in eliminating, as described above?
Yes
No
If yes, when did your patient's restriction in eliminating become a marked restriction (this is not necessarily
Year
the year of the diagnosis, as is often the case with progressive diseases)?
Feeding –
Medical doctor, nurse practitioner
, or occupational therapist
(under proposed changes)
Your patient is considered markedly restricted in feeding if, even with appropriate therapy, medication, and devices:
• he or she is unable or takes an inordinate amount of time to feed himself or herself; and
• this is the case all or substantially all of the time (at least 90% of the time).
Feeding yourself does not include identifying, finding, shopping for, or obtaining food.
Feeding yourself does include preparing food, except when the time spent is related to a dietary restriction or regime,
even when the restriction or regime is needed due to an illness or medical condition.
Is your patient markedly restricted in feeding, as described above?
Yes
No
Year
If yes, when did your patient's restriction in feeding become a marked restriction (this is not necessarily
the year of the diagnosis, as is often the case with progressive diseases)?
Dressing –
Medical doctor, nurse practitioner
, or occupational therapist
(under proposed changes)
Your patient is considered markedly restricted in dressing if, even with appropriate therapy, medication, and devices:
• he or she is unable or takes an inordinate amount of time to dress himself or herself; and
• this is the case all or substantially all of the time (at least 90% of the time).
Dressing yourself does not include identifying, finding, shopping for, or obtaining clothing.
Is your patient markedly restricted in dressing, as described above?
Yes
No
Year
If yes, when did your patient's restriction in dressing become a marked restriction (this is not necessarily
the year of the diagnosis, as is often the case with progressive diseases)?
Mental functions necessary for everyday life –
Medical doctor, nurse practitioner
,
(under proposed changes)
or psychologist
Your patient is considered markedly restricted in performing the mental functions necessary for everyday life
(described below) if, even with appropriate therapy, medication, and devices (for example, memory aids and adaptive
aids):
• he or she is unable or takes an inordinate amount of time to perform these functions by himself or herself; and
• this is the case all or substantially all of the time (at least 90% of the time).
Mental functions necessary for everyday life include:
• adaptive functioning (for example, abilities related to self-care, health and safety, abilities to initiate and respond to
social interactions, and common, simple transactions);
• memory (for example, the ability to remember simple instructions, basic personal information such as name and
address, or material of importance and interest); and
• problem-solving, goal-setting, and judgment taken together (for example, the ability to solve problems, set and keep
goals, and make the appropriate decisions and judgments).
Note
A restriction in problem-solving, goal-setting, or judgment that markedly restricts adaptive functioning, all or
substantially all of the time (at least 90% of the time), would qualify.
Is your patient markedly restricted in performing the mental functions necessary for everyday life, as
Yes
No
described above?
If yes, when did your patient's restriction in performing the mental functions necessary for everyday life
Year
become a marked restriction (this is not necessarily the year of the diagnosis, as is often the case with
progressive diseases)?
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