Chapter 2-1300 Exhibit 5

Required Medical Evidence for Specific Conditions

► Disorder of the Thyroid gland must have the following reported within the past year before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected

· Any Biopsy information

· Surgical history of site

► Anemia must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Need for transfusion and the intervals involved

· Current treatment(s) including prescriptions

o Complete Blood Count with differential (CBC with Diff)

► Tremor must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected:

o Motor strength

o Coordination

o Dexterity

· Functional Activity pertaining to Activity of Daily Living (ADL):

o Buttoning shirt

o Lacing shoes

o Performing peg tasks

· Current treatment(s)

► Peripheral Neuropathy, Polyneuropathy must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the Upper Extremities

o Motor strength

o Coordination

o Dexterity

· Functional Activity pertaining to Activity of Daily Living (ADL):

o Buttoning shirt

o Lacing shoes

o Performing peg tasks

· Physical exam findings of the Lower Extremity

o Motor strength

o Coordination

· Functional Activity pertaining to Activity of Daily Living (ADL): (Upper extremities)

o Standing (with/without mechanical support and/or assistive device)

o Walking

§ With/without assistance

§ Ability to start and stop walking

§ Limited to level surface

§ Difficulty with elevation/stairs

o Loss of stature

o Romberg Sign

· Current treatment(s)

Electromyography (EMG)

► Cataracts must have the following reported within the past year before impairment rating can take place:

Note from Physician with the following information:

Current symptoms

· Physical exam findings

· Current treatment(s)

· Surgical procedure(s)

Visual Acuity testing, corrected

Visual Field testing

► Hearing loss must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected

Tympanometry

Speech Discrimination test

Pure Tone Audiogram of both ears

► Chronic Sinusitis must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms including: headaches, balance problems

· Physical exam findings of the area(s) affected

· Current treatment(s) including prescriptions

Sinus CT

► Allergic Rhinitis must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms including headaches, balance problems

· Physical exam findings of the area(s) affected

· Current treatment(s) including prescriptions

► Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Bronchitis, Asbestosis, Chronic Respiratory condition must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information

· Current symptoms

· Physical exam findings of the area(s) affected

· Current treatment(s) including prescriptions

Pulmonary Function Test (PFT) with DL_CO with pre/post bronchodilator

► Liver Disease must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected

· Any Biopsy information

· Surgical history of site

· Nutritional Status and/or restrictions

· Current treatment(s) including prescriptions

Liver Function Test (LFTs)

► Upper Genitourinary Disease must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected

· Any Biopsy information

· Surgical history

· Current treatment(s) including prescriptions

· Need for Dialysis and its schedule

· Nutritional Status and/or restrictions

Kidney Function Test (Creatinine Clearance Test)

Serum Creatinine

Urine Analysis

► Bladder Disease must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current signs/symptoms (frequency, nocturia, loss of control, urgency, dribbling)

· Physical exam findings of the area(s) affected

· Any Biopsy information

· Surgical history

· Current treatment(s) including prescriptions

► Dermatitis, Skin Rash must have the following reported within the past twelve months before impairment rating can take place:

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area in question

· Activities of Daily Living (ADLs)

· Current treatment(s)

· Patch testing information when available

Cancers

(in alphabetical order)

All information has to be dated in the past 12 months including the diagnostic tests.

Bladder Cancer

Note from Physician with the following information:

· Current symptoms to include urinary frequency/nocturia, reflex activity of the bladder

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs)

· Current treatment(s)

Breast Cancer

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs)

· Current treatment(s)

Colon Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Presence of any stomas

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Esophageal Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Presence of any stomas

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Gallbladder Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage, and jaundice

· Presence of any stomas

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Liver Function Tests (LFTs)

Hodgkin’s Lymphoma

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs)

· Current treatment(s)

Complete Blood Count (CBC) with differential

Pathology report if available

Hypo-pharyngeal Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Presence of any stomas

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency

Laryngeal Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings

· Surgical history to the area

· Presence of any stomas

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency

Leukemias (includes Acute/Chronic Lymphocytic Leukemia (ALL/CLL) and Acute/Chronic Myelocytic Leukemia (AML/CML))

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings including any liver or spleen abnormalities

· Activities of Daily Living (ADLs)

· Current treatment(s)

Complete Blood Count (CBC) with differential

Liver Function Tests (LFTs)

Liver Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage, presence of jaundice

· Physical exam findings of the area(s) affected including presence of ascites

· Surgical history to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Liver Function Tests (LFTs)

Lung Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings

· Surgical history to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Pulmonary Function Test (PFT)

Multiple Myeloma

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings including any spleen abnormalities

· Activities of Daily Living (ADLs)

· Current treatment(s)

Complete Blood Count (CBC) with differential

Myelodysplastic Syndrome

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings including any spleen abnormalities

· Activities of Daily Living (ADLs)

· Current treatment(s)

Complete Blood Count (CBC) with differential

Nasal Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings

· Surgical history to the area

· Presence of any stomas

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency

Nasopharyngeal

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Presence of any stomas

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency

Kidney Cancer

See Renal Cancer

Pancreatic Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage, and jaundice

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Liver and Pancreatic Function Tests

Pharyngeal Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Presence of any stomas

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency

Polycythemia Vera

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings including any spleen abnormalities

· Activities of Daily Living (ADLs)

· Current treatment(s)

Complete Blood Count (CBC) with differential

Prostate Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage along with urinary control and sexual function after surgery if prostatectomy was performed

· Physical exam findings including pain induced by metastatic lesions

· Activities of Daily Living (ADLs)

· Surgical history to the affected area

· Current treatment(s)

Renal Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings

· Need for dialysis and schedule

· Kidney transplant

· Surgical history to the affected area

· Presence of any stomas

· Activities of Daily Living (ADLs)

· Current treatment(s)

Kidney Function Test (Creatinine Clearance Test)

Serum Blood Urea Nitrogen (BUN) and Creatinine

Urine Analysis

Skin Cancer

Note from Physician with the following information:

· Current symptoms

· Physical exam findings of the area(s) affected

· Physical exam findings of the area in question

· Activities of Daily Living (ADLs)

· Current treatment(s)

Small Intestinal Cancer (duodenum, jejunum, ileum)

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Presence of any stomas

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

Thyroid Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs)

· Current treatment(s) and presence of other illnesses allowing for only partial hormone replacement

Tongue Cancer

Note from Physician with the following information:

· Current symptoms including weight loss and percentage

· Physical exam findings of the area(s) affected

· Remission status and number of years in remission

· Surgical History to the area

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency

Tracheal Cancer

Note from Physician with the following information:

· Current symptoms including nutritional status, weight loss and percentage

· Physical exam findings

· Surgical history to the area

· Presence of any stomas

· Activities of Daily Living (ADLs) to include any limitation on diet

· Current treatment(s)

· Description of the Voice/Speech detailing: using the Table below

Please complete this task with and without use of assistive device for speech

ü Audibility

ü Intelligibility

ü Functional Efficiency