The Form
Has a cardiac condition to the extent that the applicants functional limitations are classified in severity as Class III or Class IV according to the standards set by the American Heart Association.
Uses portable oxygen.
Has an arterial oxygen tension (PAO2) of less than 60 mm/Hg on room air at rest.
Is restricted by a respiratory disease to such an extent that the applicants forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter.
Has lost an arm or leg and does not have or cannot use an artificial limb. Due to disability, uses a wheelchair or cannot walk without the aid of:
Another Person; A Walker; A Cane; Crutches; Braces; A Prosthetic Device: Please specify______________________________ or other Assistive Device: Please specify___________________________________
Has a disability that would be aggravated by walking 200 feet under normal environmental conditions to an extent that would be life-threatening. This condition is :_________________________________________________ Must be Specific Physical Disability
Due to disability cannot walk 200 feet without stopping to rest.
This condition is:___________________________________________________ Must be Specific Physical Disability Due to disability cannot walk without a significant risk of falling.
This condition is:____________________________________________________ Must be Specific Physical Disability
Has a specific medical condition related to pregnancy that could be aggravated by walking to the extent that the life or health of the person or fetus may be endangered (Temporary certificate only; may not exceed expected length of pregnancy)
Describe Condition: