Disabilities

Mobility Impairment

Yes

No

Hearing Impairment (partial or complete hearing loss)

Vision Impairment (low vision or blindness)

Speech Impairment (difficulty or inability to speak clearly)

Details / Notes

Cognitive or Learning Disability (general mental or learning delay)

Autism Spectrum Disorder (ASD)

Down Syndrome

ADHD (Attention Deficit Hyperactivity Disorder)

Other Developmental Condition

Cerebral Palsy (CP)

Epilepsy / Seizure Disorder

Muscular Dystrophy

Parkinson's Disease

Brain Injury (Traumatic or Stroke-related)

Other Neurological Disorder

Other Neurological Condition

Wheelchair

Cane / Crutches / Walker

Prosthetic Limb

Hearing Aid

Feeding Tube

Cochlear Implant

Glasses / Contact Lenses

Mobility Scooter

Speech Device / Communication Board

Additional Notes for Care Providers