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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