Disability Tax Credit Certificate (T2201)

## Disability Tax Credit Certificate **Patient Information** * **Patient Name:** John Smith * **Date of Birth:** 12/03/1960 * **Address:** 123 Main Street, Anytown, AB T1T 1T1 * **Health Card Number:** 1234567890 **Medical Practitioner Information** * **Name:** Dr. Emily Carter * **Address:** 456 Oak Avenue, Anytown, AB T1T 2T2 * **Telephone Number:** (555) 123-4567 * **Registration Number:** 12345 **Medical Condition(s)** * **Primary Diagnosis:** Severe Osteoarthritis * **Secondary Diagnosis:** Major Depressive Disorder **Description of Impairment** Mr. Smith suffers from severe osteoarthritis, significantly limiting his mobility and ability to perform activities of daily living. He experiences chronic pain, stiffness, and reduced range of motion in his hips and knees. This condition requires regular medical appointments, physiotherapy, and the use of assistive devices such as a cane. Additionally, Mr. Smith is diagnosed with Major Depressive Disorder, which further impacts his ability to function due to fatigue, low mood, and difficulty concentrating. His mental health condition requires ongoing medication and therapy. **Duration of Impairment** * **Onset:** Osteoarthritis diagnosed in 2018, Major Depressive Disorder diagnosed in 2020. * **Expected Duration:** Permanent **Impact on Activities of Daily Living** Mr. Smith's impairments significantly restrict his ability to perform basic activities of daily living, including: * **Walking:** Limited to short distances, requiring the use of a cane. * **Dressing:** Requires assistance with putting on and taking off clothes. * **Bathing:** Requires assistance to ensure safety and prevent falls. * **Eating:** Requires assistance with meal preparation and eating due to pain and mobility issues. * **Other:** Difficulty with household chores, managing finances, and social activities. **Treatment and Management** * **Medications:** Pain medication (e.g., NSAIDs, opioids), antidepressants. * **Therapies:** Physiotherapy, psychotherapy. * **Assistive Devices:** Cane, walker, grab bars. * **Other:** Regular medical check-ups. **Certification** I certify that the above information is true and accurate to the best of my knowledge. Mr. Smith's impairments meet the criteria for the Disability Tax Credit. **Date:** 1 November 2024 **Signature:** Dr. Emily Carter **Stamp/Seal:** [Insert Clinic Stamp Here]