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1. I find this individual has been or will be totally and permanently disabled to the extent they are unable to work |
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(If this box is |
full time at any job due to a physical or mental impairment. This disability is expected to last 12 months or |
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more. Select the Qualifying Disability: |
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checked, |
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Respiratory disorders, such as cystic fibrosis, chronic persistent lung infections, or chronic pulmonary |
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please also |
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insufficiency; |
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select the |
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Cardiovascular disorders, such as chronic heart failure despite medication, congenital heart disease, or |
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qualifying |
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recurrent arrhythmias not related to a reversible cause; |
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disability- |
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Digestive disorders, such as liver dysfunction or gastrointestinal hemorrhage; |
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more than 1 |
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Genitourinary disorders, such as chronic renal failure resulting in chronic hemodialysis; |
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may be |
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Hematological disorders, such as sickle-cell disease, hemophilia, or aplastic anemia; |
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selected) |
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Congenital disorders, such as fragile X syndrome or phenylketonuria (PKU); |
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Neurological disorders, such as multiple sclerosis, muscular dystrophy, head trauma, |
or cerebral palsy; |
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Disorders of speech or other senses, such as blindness, tinnitus in combination with progressive hearing |
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loss, or loss of speech; |
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Musculoskeletal disorders, such as a gross anatomical deformity, spinal stenosis or other spinal disorder |
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resulting in nerve root compression, or amputation of both hands; |
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Mental or cognitive disorders, such as schizophrenia, affective disorders, personality disorders, |
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developmental disabilities, or substance abuse to the extent that the disorder results in at least two of the |
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following activities: -Marked restriction of activities of daily living; -Marked difficulties in maintaining social |
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functioning; -Marked difficulties in maintaining concentration or pace; -Repeated decompensation for |
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extended periods. |
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Other (please define):__________________________________________________________________ |
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2. I find this individual is not totally disabled but does have a physical or mental impairment that substantially |
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precludes this person from engaging in his/her usual occupation. This condition has been or will be for a |
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period of (check one): 6 months 7 months 8 months 9 months 10 months 11 months 12 months |
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Physical exertion is limited to (check all that apply): light sedentary moderate |
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Please identify the less severe conditions preventing the individual from employment:___________________ |
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_______________________________________________________________________________________ |
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3. I find this individual does not have a total physical or mental impairment that has lasted or is expected to last |
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6 months. |
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4. PRIMARY DIAGNOSIS IS ALCOHOLISM OR CONTROLLED SUBSTANCE ADDICTION |
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Checking this box means there is no other physical or mental disability(ies) that precludes this person from |
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working other than his/her alcohol or controlled substance addiction. (If this box is checked, the individual |
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will be offered treatment through ADAD and will be expected to work once treatment is complete.) |
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If this is a Medical Re-examination, please answer this question if number 2 above was checked |
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Yes No |
Has there been improvement in this client’s physical/mental condition that would allow the client to return to work? |
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This form may be completed by the following: (Please check one) |
PRINTED NAME, ADDRESS, AND PHONE NUMBER. |
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Examining physician |
Physician assistant certified in Colo. |
This is needed to insure the accuracy of this report |
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Psychiatrist |
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Advanced practice nurse |
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Registered nurse licensed in Colorado |
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SIGNATURE: |
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STATE |
LICENSE # |
DATE OF EXAM |
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