5. Prognosis of the disability/condition
Will the condition:
Remain static □ Have periods of relapse/remission □
If prognosis is uncertain, please give more detail:
Be progressive ___
6. Describe in detail measures currently being taken to treat the disability (e.g. medication, therapy etc.)
___
7. If the applicant is Blind/Vision Impaired, state the visual acuity scores, field of vision loss, loss of near vision, central vision or peripheral vision where appropriate.
8. If the applicant has a Physical condition, state the level of physical or mobility difficulty, and any other relevant information. (For Scoliosis, please provide degree of curvature of the spine).
Where a Consultant has completed this form, Consultant must sign below:
Official Stamp Required:
Consultant’s signature: Date: IMC Number:
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Where the applicant's GP has completed this form, GP must sign below:
Official Stamp Required:
Name of GP: ___
GP's signature:
Date:
IMC Number:
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