"Medical Conditions Form" - Colorado

Medical Conditions Form is a legal document that was released by the Colorado Department of Public Health and Environment - a government authority operating within Colorado.

Form Details:

  • Released on October 1, 2016;
  • The latest edition currently provided by the Colorado Department of Public Health and Environment;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Public Health and Environment.

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Download "Medical Conditions Form" - Colorado

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Last Name:
First Name:
Date of Birth:
Select all that apply:
Allergies (severe)
Fetal Alcohol Syndrome
Arthritis or other joint problems
Gastrointestinal problems
Asthma
Genitourinary problems
Attention deficit disorder or attention deficit
HIV/AIDS
hyperactivity disorder (ADD or ADHD)
Autism Spectrum Disorder (including Asperger’s
Hydrocephalus/anencephaly/microcephaly
disorder, pervasive development disorder)
Blood problems (such as anemia, sickle cell
Immune system disorder
disease, hemophilia)
Brain injury (acquired)
Kidney disease
Brain injury (traumatic)
Learning problems
Cardiac defect
Limb reduction anomalies
Mental health problems – diagnosed (such as
Cardiac disease
depression, bipolar disorder, personality disorder,
schizophrenia)
Cerebral Palsy
Mental health/behavioral problems - undiagnosed
Chromosomal disorders & genetic syndromes
Metabolic disorders
(other than Down syndrome)
Chronic ear infections
Migraines or frequent headaches
Circulatory system problems (excluding cardiac
Movement disorders (such as Tourette syndrome,
problems)
tics)
Cleft lip and/or palate
Musculoskeletal disorders
Congenital anomalies
Neoplasms - benign
Connective tissue disorders (such as osteogenesis
Neoplasms - malignant
imperfecta)
Cystic fibrosis
Neurofibromatosis
Degenerative neuromuscular disorders (including
Neurological disorders
muscular dystrophy)
Developmental delay - cognitive
Newborn Intensive Care Unit (NICU) graduate
Developmental delay – global
Obesity
Developmental delay - motor
Prematurity (<37 weeks by date)
Developmental delay - speech
Respiratory conditions
Developmental disability
Skin & subcutaneous tissue problems
Diabetes
Spina bifida
Down Syndrome
Spinal disorders
Eating disorders
Spinal injuries
Endocrine disorder (other than diabetes)
Trouble hearing/deafness
Epilepsy or seizure disorder
Trouble seeing/blindness
Failure to thrive
Unknown
Other:
HCP Care Coordination _ CYSHCN Medical Conditions _ 10.01.2016
1
Last Name:
First Name:
Date of Birth:
Select all that apply:
Allergies (severe)
Fetal Alcohol Syndrome
Arthritis or other joint problems
Gastrointestinal problems
Asthma
Genitourinary problems
Attention deficit disorder or attention deficit
HIV/AIDS
hyperactivity disorder (ADD or ADHD)
Autism Spectrum Disorder (including Asperger’s
Hydrocephalus/anencephaly/microcephaly
disorder, pervasive development disorder)
Blood problems (such as anemia, sickle cell
Immune system disorder
disease, hemophilia)
Brain injury (acquired)
Kidney disease
Brain injury (traumatic)
Learning problems
Cardiac defect
Limb reduction anomalies
Mental health problems – diagnosed (such as
Cardiac disease
depression, bipolar disorder, personality disorder,
schizophrenia)
Cerebral Palsy
Mental health/behavioral problems - undiagnosed
Chromosomal disorders & genetic syndromes
Metabolic disorders
(other than Down syndrome)
Chronic ear infections
Migraines or frequent headaches
Circulatory system problems (excluding cardiac
Movement disorders (such as Tourette syndrome,
problems)
tics)
Cleft lip and/or palate
Musculoskeletal disorders
Congenital anomalies
Neoplasms - benign
Connective tissue disorders (such as osteogenesis
Neoplasms - malignant
imperfecta)
Cystic fibrosis
Neurofibromatosis
Degenerative neuromuscular disorders (including
Neurological disorders
muscular dystrophy)
Developmental delay - cognitive
Newborn Intensive Care Unit (NICU) graduate
Developmental delay – global
Obesity
Developmental delay - motor
Prematurity (<37 weeks by date)
Developmental delay - speech
Respiratory conditions
Developmental disability
Skin & subcutaneous tissue problems
Diabetes
Spina bifida
Down Syndrome
Spinal disorders
Eating disorders
Spinal injuries
Endocrine disorder (other than diabetes)
Trouble hearing/deafness
Epilepsy or seizure disorder
Trouble seeing/blindness
Failure to thrive
Unknown
Other:
HCP Care Coordination _ CYSHCN Medical Conditions _ 10.01.2016
1