Heart Disease: Aortic aneurysm Coronary artery bypass/angioplasty Angina History of heart attack/Myocardial infarction Cardiac dysrhythmia (abnormal heart rate) History of myocarditis/Pericarditis/ heart Congenital heart failure infection Congestive Heart Failure (CHF) Pulmonary hypertension Mobile Limitations: Amputee Manual wheelchair Require walker, cane, or Confined to bed Paraplegia crutches Electric wheelchair or Quadriplegia Require wheelchair scooter Weight over 300 pounds Other mobility impairment: Neurological, Behavioral, Cognitive Conditions: Anxiety (extreme) Developmentally delayed Migraine or frequent Autism spectrum disorder Difficulty understanding headaches Bipolar disorder verbal or written instructions Neurological disease Cerebral Intellectual Disability PTSD Cognitive impairment Memory impaired, Prone to wandering Confused easily dementia, Alzheimer’s Seizure disorder/epilepsy Developmental disability Schizophrenia Other psychiatric conditions: Organ transplants: Bone marrow Kidney Pancreas Bowel Liver Heart Lung Powered Medical Devices: Apnea monitor Nebulizer for breathing problems IV pump Oxygen concentrator Kidney dialysis Sleep apnea, CPAP, BRAP device Life sustaining medication requiring Ventilator/Respirator refrigeration Other life-sustaining device or equipment dependent on electricity: Prescription Medications:
Heart Disease: Aortic aneurysm Angina Cardiac dysrhythmia (abnormal heart rate) Congenital heart failure Congestive Heart Failure (CHF) Coronary artery bypass/angioplasty History of heart attack/Myocardial infarction History of myocarditis/Pericarditis/ heart infection Pulmonary hypertension Mobile Limitations: Amputee Confined to bed Electric wheelchair or scooter Manual wheelchair Paraplegia Quadriplegia Require walker, cane, or crutches Require wheelchair Weight over 300 pounds Other mobility impairment: Neurological, Behavioral, Cognitive Conditions: Anxiety (extreme) Autism spectrum disorder Bipolar disorder Cerebral Cognitive impairment Confused easily Developmental disability Developmentally delayed Difficulty understanding verbal or written instructions Intellectual Disability Memory impaired, dementia, Alzheimer’s Migraine or frequent headaches Neurological disease PTSD Prone to wandering Seizure disorder/epilepsy Schizophrenia Other psychiatric conditions: Organ transplants: Bone marrow Bowel Heart Kidney Liver Lung Pancreas Powered Medical Devices: Apnea monitor IV pump Kidney dialysis Life sustaining medication requiring refrigeration Nebulizer for breathing problems Oxygen concentrator Sleep apnea, CPAP, BRAP device Ventilator/Respirator Other life-sustaining device or equipment dependent on electricity: Prescription Medications:
EMI-form.docx