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State Alabama Arizona California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina Tennessee Texas Vermont Virginia Washington Wisconson Exp. Date  

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Requested Illustration:

1. PLEASE LIST THE DATE OF THE FIRST DIAGNOSIS:

2. PLEASE NOTE THE CURRENT FUNCTIONAL STAGE OF THE 
STAGE 1 - UNILATERAL INVOLVEMENT

STAGE 2 - BILATERAL INVOLVEMENT, BUT NORMAL STANCE 

STAGE 3 - BILATERAL INVOLVEMENT WITH MILD POSTURAL IMBALANCE BUT ABLE TO LEAD AN INDEPENDENT LIFE 

STAGE 4 - BILATERAL INVOLVEMENT WITH POSTURAL INSTABILITY, REQUIRES SUBSTANTIAL HELP

STAGE 5 - SEVERE DISEASE, RESTRICTED TO BED OR WHEELCHAIR

3. HAS THERE BEEN ANY EVIDENCE OF PROGRESSION?
Yes No IF YES, PLEASE DETAIL

4. PLEASE NOTE IF ANY OF THE FOLLOWING HAS OCCURRED: (CHECK ALL THAT APPLY)
DEMENTIA
FALLS
RECURRENT INJURIES
ASPIRATION
MEMORY PROBLEMS

5. CLIENT'S OCCUPATION FULL TIME PART TIME

6. DOES THE CLIENT EXERCISE THREE OR MORE TIMES PER WEEK?
Yes No IF YES, PLEASE DETAIL

7. HAS A PARENT, BROTHER OR SISTER DIED PRIOR TO AGE 65, OTHER THAN BY ACCIDENT?
Yes No IF YES, PLEASE DETAIL

8. PLEASE LIST ANY OTHER ILLNESSES OR IMPAIRMENTS, ALONG WITH ANY AND ALL MEDICATIONS CURRENTLY BEING TAKEN, INCLUDE THE DOSAGE AND FREQUENCY OF EACH: