Yes   No   The student has limited strength, vitality or alertness due to chronic
                 or acute health problems such as a heart condition, tuberculosis,
                 rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia,
                 epilepsy, lead poisoning, leukemia, or diabetes that adversely
                 affects the student's educational performance.

Yes   No   The disability adversely affects the student's educational
                 performance in the regular curriculum, with or without accommodations or
                 modifications, and

Yes   No  because of that disability the student needs special education.

Yes   No  The student has a medical diagnosis of a chronic or acute health
                problem. (REQUIRED)

Student Name: _________________ CST Date: __________