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Check any conditions that pertain to you.
Acoustic Neuroma (unoperated)
Acromegaly
ADL Deficit
AIDS/ARC
Adult Day Care within 6 months
Agoraphobia
Alcohol 4 or more drinks daily
Alcoholism with any current alcohol use
ALS
Alzheimer's Disease
Amputation due to disease, other than cancer
Amputation 2 or more limbs
Amyloidosis
Ankylosing Spondylitis
Anorexia
Aplastic Anemia
Arnold-Chiari Malformation
Arrhythmia (uncontrolled)
Arteriovenous Malformation (AVM) (unoperated)
Arthritis requiring narcotic pain medication
Asperger's Syndrome
Assisted Living Facility (resident within 6 months)
Ataxia
Avascular Necrosis (unoperated)
Back pain (disabling or requiring narcotic pain medication)
Bell's Palsy (present)
Benign Positional Vertigo (BPV) (with falls)
Bipolar (diagnosed within 3 years, psychiatric hospitalization within 2 years, 2 or more psychiatric hospitalizations)
Blindness (not adapted or with ADL/IADL limitations)
Bowel Incontinence
Buerger’s Disease
Bulimia
Bullous Pemphigoid (active)
Cardiomyopathy (dilated)
Castleman’s
Cerebral Aneurysm (unoperated)
Cerebral Palsy
Cerebrovascular Accident (CVA) (2 or more)
Charcot Marie Tooth
Chronic Pain (requiring narcotics, TENS unit, implantable stimulator, ADL/IADL deficit)
Cirrhosis
Complex Regional Pain Syndrome
Confusion
Connective Tissue Disease
Cor Pulmonale
CREST Syndrome
Crohn’s (multiple flares or with complications)
Cushing’s Syndrome
Cystic Fibrosis
Defibrillator (implanted)
Dementia
Dermatomyositis
Diabetic Complications (neuropathy, nephropathy, retinopathy, gastropathy)
Dialysis
Dilated Cardiomyopathy
Disabled, except VA disability
Down’s Syndrome
Dwarfism
Dystonia
Ehlers-Danlos
Epilepsy (>2 seizures/year)
Epstein-Barr Virus (within 2 years)
Fibromuscular Dysplasia
Fibromyalgia (disabling)
Frailty
Friedrich’s Ataxia
Gaucher’s
Glomerulonephritis
Head Injury (residual functional or cognitive impairment)
Heart Transplant
Hemiplegia
Hemophilia
Hepatitis (chronic, active, alcohol related, residual liver damage)
HIV Positive
Hoarding
Home Health Care (within 6 months)
Huntington’s Chorea
Hydrocephalus
IADL Deficit
Immune Deficiency
Implantable Stimulator
Irritable Bowel Syndrome (uncontrolled or with weight loss)
Kidney Failure
Kidney Transplant
Lacunar Infarct (2 or more)
Liver Transplant
Lou Gehrig’s Disease
Lupus (systemic)
Marfan’s Syndrome
Medicaid Recipient
Memory Loss
Mental Retardation
Mixed Connective Tissue Disease
Multiple Myeloma
Multiple Sclerosis
Muscular Dystrophy
Myelodysplasia
Myelodysplastic Syndrome
Myelofibrosis
Myasthenia Gravis (generalized)
Neurofibromatosis
Neurogenic Bowel or Bladder
Neuropathy (related to diabetes or alcohol, or with history of falls or skin ulcers), or severe
Nursing Home resident (within 6 months)
Occupational Therapy (within 3 months)
Organ Transplant
Organic Brain Syndrome
Osteoporosis (T score -4.0 or worse)
Oxygen use
Pancreas Transplant
Pancreatitis (alcohol related, or >2 episodes)
Paralysis
Paraplegia
Parkinson’s Disease
Pemphigus Vulgaris
Physical Therapy (within 3 months)
Pick’s Disease
Polycystic Kidney Disease
Polymyositis
Polyneuropathy
Post Herpetic Neuralgia
Post Polio Syndrome (with progressive weakness, fatigue, or limitations)
Pregnancy (Is pregnant or receiving medical treatment to become pregnant)
Primary Biliary Cirrhosis
Pseudotumor Cerebri
Psychiatric Hospitalization (within 3 years, or 2 or more)
Psychosis
Pulmonary Hypertension
Quad Cane use
Quadriplegia
Reflex Sympathetic Dystrophy
Retinal Vein Occlusion (2 or more)
Schizophrenia
Scleroderma
Sclerosing Cholangitis
Shingles (within 6 months)
Sjogren’s Syndrome (systemic)
Social Withdrawal
Speech Therapy (within 3 months)
Spina Bifida
Stroke (2 or more)
Surgery (requiring general anesthesia scheduled or planned)
Systemic Lupus
Thalassemia Major
Thrombocytosis
Transient Ischemic Attack (TIA) (2 or more)
Tuberculosis
Underweight
Ventriculoperitoneal shunt
Von Willebrand’s Disease
Walker use
Wegener’s Granulomatosis
Weight loss (unintentional or unexplained)
Wheelchair use
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