Form Cg-719k - Medical Evaluation Report Page 5
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9Page 5 of 9 of CG-719K Rev. 01-09
1.
3.
5.
Identify the Condition
Is Condition Controlled?
Prognosis
2.
4.
6.
List Any Limitations
Approximate Date of Diagnosis
Additional Information
YES
NO
YES
NO
1.
Ear
surgery,
45.
Kidney stones
2.
Hearing loss, hearing aid
46.
Protein/sugar/blood in urine
3.
Impaired speech or stuttering
47.
Back surgery or injury
4.
Deformities of face
48.
Ruptured/herniated disc
5.
Open tracheostomy
49.
Fractures requiring surgery
6.
Poor vision
50.
Limitation of any major joint
7.
History of eye disease or injury
51.
Bone or joint surgery
8.
History of eye surgery
52.
Dislocated joint
9.
Abnormal color vision
53.
Recurrent neck or back pain
10.
Glaucoma
54.
Swollen or painful joint
11.
Asthma
55.
Arthritis or bursitis
12.
Emphysema or COPD
56.
Trick or locked knee
13.
Collapsed lung/pneumothorax
57.
Amputation or prosthesis
14.
Irregular heart beat
58.
Carpal tunnel
15.
Heart murmur or valve replacement
59.
Difficulty walking or climbing
16.
Chest pain or angina
60.
Sciatica or nerve pain
17.
Heart attack/ myocardial infarction
61.
Other bone/joint disorder
18.
Congestive heart failure
62.
Motion/sea sickness
19.
Heart surgery/stent/angioplasty
63.
Impaired balance, or balance disorder or difficulty
20.
Pacemaker or defibrillator
64.
Vertigo or dizziness
21.
Any other heart condition
65.
Numbness or paralysis
22.
High blood pressure/hypertension
66.
Head injury or skull fracture
23.
Aneurysm or blockages
67.
Seizures or epilepsy
24.
Pulmonary embolus or blood clots
68.
Recurrent headaches
25.
Gastrointestinal bleeding or ulcers
69.
Narcolepsy
26.
Crohn’s disease or ulcerative colitis
70.
Sleep apnea
27.
Hepatitis or jaundice
71.
Restless leg
28.
Gallbladder problems or stones
72.
Fainting spells or loss of consciousness
29.
Intestinal surgery
73.
Stroke or TIA
30.
Any form of cancer
74.
Brain tumor
31.
Anemia
75.
Other brain or nerve disease
32.
Hemophilia or polycythemia
76.
ADD, ADHD, or bipolar
33.
Any other blood disorders
77.
Depression
34.
Thyroid disease
78.
History of suicide attempt
35.
Diabetes
79.
Schizophrenia
36.
HIV or AIDS
80.
Anxiety
37.
Lymphoma or leukemia
81.
Alcohol or substance abuse
38.
Tuberculosis
82.
Loss of memory or amnesia
39.
Neurofibromatosis
83.
Other psychiatric disease or counseling
40.
Skin tumors or cancer
84.
Sleepwalking
41.
Scleroderma
85.
Bedwetting since age 12
42.
Lupus
86.
Sex change
43.
Kidney transplant or dialysis
87.
Allergic reactions
44.
Kidney disease or cancer
88.
Any other disease, surgery or hospitalization
Condition #
Comment
Applicant Name: _______________________________________
Date of Birth:____________________________
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