GOVERNMENT OF THE EPUBLIC OF TRINIDAD AND TOBAGO. Pex MINISTRY OF SOCIAL DEVELOPMENT AND FAMILY SERVICES DISABILITY ASSISTANCE GRANT Children (Under 18 Years) MEDICAL REPORT Beneficiary Information Poll Name Also Known As Date of Binh Age Gender Aes 2.1: Existing Diagnosis (Attach Copies of relevant documents) Diagnosis 2.2: Medical Diagnosis Resulting in Disability Is the condition permanent? Yes:C] NofE] If no, please sate the duration: Dingnosis 23: Physial Disability (Visual: Nonef]—MildE Moderate) Isthe condition permanent? YesE] NoL] Ifo, please state the duration Diagnosis evereE] CompleieL] Not SpecifiedE] Not Applicable (ii) Hearing: None] MiléE]—ModerateE]_—SevereC]_—Complete(]} Not Specified] Is the condition permanent? YesE No] If no, please state the duration: Diagnosis Not Applicable] i) Motor Funetions: Nonef MilE] ModerateE) —Severe€] Complete Not Specified Is the condition permanent? YesE] NoiL] 1fno, please state the duration Diagnosis Not Applicablet]2d: Developmental Disability Communications Skills Expression NoneE] Mild] Moderate CompleteE] Not Specified] _Not ApplicubleL] Reveption None] MildE] Moderate Complete] Not SpecitiedL] Not ApplicubleD] SeleCare NoneE] MildC] Moderate] SevereL] CompleteL] Not SpecifiedL] Not ApplicableL] Social / Emotional NoneL] MildC] ModerateC] SevereL] CompleteL] Not SpecifiedL] Not Applicable] Cognitive Intellectual | None] MildL] ModerateE) Severe] CompleteL] Not SpecifiedL] _ Not ApplicabieO] Is the condition permanent? Yes No 1 Ino, please state the duration: Diagnosis: Special Education: YesC] Full Time Part Time: Nol] Teachers Aid: -YesEl——-Nof Speech Therapy: YesC] -NoL]_—_Language Therapy: YesC]_ No{] Personal Care Assistance: YesE] —-NoL] Other] Please specify 2.5: Mental Health Nonef1 MildX] = Moderate] Severe] Complete] Not Specified] Not ApplicableD Is the condition permanent? Yes NoD _ Ifno, please state the duration: Diagnosis 2.6: Other Information Provide any other information which is relevant to determine the extent of the child’s disability 2.1: Overall Assessment Impact of disability on the child’s level of functioning NoneX = Mild] ModerateL Severe] CompleteX] Not Specified] Not Applicable] Is the condition permanent? Yes No 0 If'no, please state the duration: Status to be reviewed in: Medical Officer: Medical Board Number: