GOVERNMENT Photo
of JAMAICA
MINISTRY OF LABOUR
& SOCIAL SECURITY
Jamaica Council for Persons with Disabilities
Medical Report-ADULT
JCPD ADULT MEDICAL FORM
Hearing/Visual Assessment
Kindly complete this form for all clients based on the disability identified. For guidelines on the criteria for identifying
the disability please see attached guidelines. Form is to be completed in BLOCK letters
Title: Mr. c Miss. c Mrs. c Dr. c Professor c
Name __________________________________________________________________________ Male c Female c
Last Name First Name Middle Name(s)
Home Address: ____________________________________________________________________________________
Usual or Previous occupation _____________________________ TRN # ___________________________________
Current Occupation (if any) __________________________________________________________________________
Type of Disability: _________________________________________________________________________________
Nature of Disability:
Temporary c Permanent c Progressive c Improving c Static c
Other (specify) _____________________________________________________________________________________
Degree of disablement:
Minimal c Mild c Moderate c Severe c Profound c
Treatment (if any) __________________________________________________________________________________
Treatment, assistive devices / prosthetic appliances or aids (specify):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Date of Disablement / Diagnosis : __________/_________/_________ Age of First Diagnosis : ___________
Yr. Mth Day
Medical diagnosis (Cause):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
JCPD REGISTRATION FORM MEDIC-ADULT/A001, Revised APRIL 2018
To be completed if client has visual or hearing disabilities
Hearing/Visual Assessment –to be completed by Ophthalmologist or Audiologist
Hearing: Left c Right c Both c
Vision: Left c Right c Both c
(Explain) ______________________________________________________________________________________
______________________________________________________________________________________________
Level of Functioning:
Normal c Mildly Improved c Moderately Impaired c Severely Impaired c
Level of social and family support:
Very Good c Good c Fair c Poor c
Degree of hearing loss: db=decibels
c Mild Sounds softer than 25 dB to 40 dB are not detected
c Moderate Sound softer than 40 dB to 65 dB are not detected
c Severe Sound softer than 65 dB to 90 dB are not detected
c Profound Sounds softer than 90 dB are not detected
Summary
MAIN MEDICAL PROBLEM(S) In order of priority ________________________________________________________
RECOMMENDATION(S) Who will implement them ________________________________________________________
CRITERIA for IMPROVEMENT: ___________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
________________________________________________________________ __________/_______/________
SIGNATURE OF APPLICANT Date: Yr. Mth Day
Name of Audiologist/Ophthalmologist: ______________________________ OFFICIAL
STAMP
Signature of Audiologist/Ophthalmologist: __________________________
Address/Place of Practice: ___________________________________________________________________________
Contact Number: ___________________________________ Email: ________________________________________
Date of Completion: _____________/_________/__________
Yr. Mth Day
JCPD REGISTRATION FORM MEDIC-ADULT/A001, Revised APRIL 2018
