Conditions Checker
Chart to check eligibility of multiple conditions
Name
First Name
Last Name
Email
example@example.com
Please list all your conditions in the following table.
Tick box if formally diagnosed by appropriate medical professional (GP or Specialist)
Tick box if all reasonable treatment providing improvement is exhausted.
Tick box if no improvement is expected in at least 2 years.
Choose the appropriate table (or tables) for your condition.
Choose which points rating fits your impairments (5,10,20,30).
Rows
Diagnosis
Diagnosed
Treated
Permanent
Table
Rating
Condition 1
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Mild 5
Moderate 10
Severe 20
Extreme 30
Condition 2
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Mild 5
Moderate 10
Severe 20
Extreme 30
Condition 3
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Mild 5
Moderate 10
Severe 20
Extreme 30
Condition 4
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Mild 5
Moderate 10
Severe 20
Extreme 30
Condition 5
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Mild 5
Moderate 10
Severe 20
Extreme 30
Should be Empty: