Diagnoses Cue Sheet, P-00920

Children’s Long-Term Support Functional Screen

Diagnoses Cue Sheet

This alphabetical list of diagnoses indicates which box screeners should check on the Diagnoses table of the Children’s Long-Term Support Functional Screen (CLTS FS). For every diagnosis, the screener should: 1. See if it is listed in the CLTS FS Diagnoses Table and check relevant box on the table. Use the Search icon to help find the condition you are seeking. 2. If not on the CLTS FS Diagnoses Table, look for it in this Diagnoses Cue Sheet. If present here, check the box (es) on CLTS FS Diagnosis Table as indicated here. Also list the name of the specific condition/syndrome/diagnosis in the note section on the Diagnosis page. 3. If the diagnosis is not listed in this Cue Sheet, then check Diagnoses Table “Other,” and write it in. 4. Do not write in a diagnosis in “Other” until after making sure it is not on this Cue Sheet. 5. Do not guess which diagnoses on the CLTS FS diagnosis table to check. (See instructions.)

Screeners should ignore letters or numbers before or after diagnoses. You can also ignore the following adjectives appearing before or after diagnoses:

Words to Ignore:

Active History of (check the diagnosis IF it is still current; see instructions) Acute Idiopathic Adolescent Intermittent Bilateral, left, right, Mild, Moderate Childhood Neonatal Classic NOS (means “not otherwise specified”) Congenital Primary End Stage Secondary General, generalized Severe Genetic S/P status post (check the diagnosis IF it is still current; see instructions) Juvenile Status post (check the diagnosis IF it is still current; see instructions) Chronic Recurrent Hereditary

Common Abbreviations:

FX Fracture R/O Rule Out LLE left lower extremity (leg) RLE right lower extremity (leg) LLL left lower lobe of lung RLL right lower lobe of lung LUE left upper extremity (arm) RUE right upper extremity (arm) LE Lower extremities (legs) RUL right upper lobe of lung NOS not otherwise specified

For “Educational diagnosis of [anything]”: Include in Note Section, do not check a diagnosis For “Possible diagnosis of [anything]”: Include in Note Section, do not check a diagnosis For “Suspected diagnosis of [anything]”: Include in Note Section, do not check a diagnosis For “Rule out diagnosis of [anything]”: Include in Note Section, do not check a diagnosis For “Allergic to [anything]”: Allergy

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 1 of 30 Chromosomal Disorders: • There are 23 pairs of chromosomes, 46 chromosomes in all • Mind your ps and qs; chromosome deletions are often labeled as either [p] or [q]. • In medical reports it may be noted as a deletion or minus or [-]; these are all the same. • If the medical report indicates the specific band, for example 11.21, this is not important for purposes of this table. • Unbalance and Unbalance Translocation are the same thing

If You See This Diagnosis Check This on CLTS FS Diagnosis Table Genetic / Chromosomal Disorder AND 10q deletion Developmental Delay 11;22 Unbalance Translocation (Robertsonian Genetic / Chromosomal Disorder AND Translocation) Developmental Delay 12p deletion Genetic / Chromosomal Disorder 18q deletion Genetic / Chromosomal Disorder 19 Unbalanced Translocation Genetic / Chromosomal Disorder 1p deletion Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND 1p36 Deletion Mosaic Musculoskeletal Disorder Genetic / Chromosomal Disorder AND 1p36 Deletion Syndrome Cognitive Disability 1st Degree Heart Block Cardiac Condition 22q deletion Genetic / Chromosomal Disorder 22q13 Deletion Syndrome (Phelan-McDermid Genetic / Chromosomal Disorder AND Syndrome) Developmental Delay 4-Hydroxybutyric Aciduria (SSADH-D) Metabolic Disorder Genetic / Chromosomal Disorder AND 4p Deletion Syndrome (Wolf-Hirschhorn) Cognitive Disability 4q deletion Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND 5p deletion (Cri Du Chat Syndrome) Cognitive Disability 8p deletion Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND 9p deletion (Alfi Syndrome) Cognitive Disability Abscess of Liver Liver Disease (Hepatic Failure, Cirrhosis) Absence Of Corpus Callosum Brain Disorder (other than seizures) or Brain Damage Achalasia Digestive System Disorder Achilles Tendon Contractures Contracture / Connective Tissue Disorder Achondroplasia Musculoskeletal Disorder Acid Peptic Disease Digestive System Disorder Acid Reflux Digestive System Disorder Acidosis Metabolic Disorder Acne Include in Note Section, no Diagnosis checked Immune Deficiency (Do not include in notes due to Acquired Immune Deficiency Syndrome (AIDS) confidentiality) Acrocallosal Syndrome Brain Disorder (other than seizures) or Brain Damage Actinic Keratosis Skin Disease Acute Disseminated Encephalomyelitis (ADEM) Brain Disorder (other than seizures) or Brain Damage Acute Lymphocytic Leukemia (ALL) Cancer Acute Myelocytic Leukemia (AML) Cancer Adaptive Behavior Delay Include in Note Section, no Diagnosis checked Addiction To [A Drug Other Than Nicotine or Substance-Related Disorder (must verify diagnosis) Caffeine]

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 2 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Addison’s Disease Metabolic Disorder Adenocarcinoma Cancer Adjustment Disorder Adjustment Disorder (must verify diagnosis) Adrenal Hyperplasia Endocrine Disorder (not Diabetes) Adrenal Insufficiency Endocrine Disorder (not Diabetes) Adrenoleukodystrophy (ALD) Metabolic Disorder Agenesis of the Corpus Collosum (ACC) Brain Disorder (other than seizures) or Brain Damage Aggressive Behavior Disorder Include in Note Section, no Diagnosis checked Agoraphobia Anxiety Disorder (must verify diagnosis) Agranulocytosis Immune Deficiency Aicardi Syndrome Immune Deficiency Immune Deficiency (Do not include in notes due to AIDS (Acquired Immune Deficiency Syndrome) confidentiality) Akathesia (Legs Tighten Up) Neuromuscular Disorder Alagille Syndrome Genetic / Chromosomal Disorder Albinism Genetic / Chromosomal Disorder Alcohol Related Neurodevelopmental Disorder Fetal Alcohol Syndrome / Effect Alcoholism / Alcohol Abuse or Addiction Substance-Related Disorder (must verify diagnosis) Genetic / Chromosomal Disorder AND Alfi Syndrome (9p deletion) Cognitive Disability Allergic to [anything] Allergy Alopecia Include in Note Section, no Diagnosis checked Alpha-1 Antitrypsin Deficiency Metabolic Disorder Alternating Hemiplegia Paralysis, Other than Spinal Cord Injury Ambiguous Genitalia Congenital Abnormality Ambloyopia (Lazy Eye) Include in Note Section, no Diagnosis checked Amniotic Bands Syndrome Congenital Abnormality Amputation / Missing Limb or Part of Limb Limb Missing, Severe Limb Abnormality, Arthrogryposis Amyoplasia Musculoskeletal Disorder Amyotrophic Lateral Sclerosis (ALS) Multiple Sclerosis or ALS Anencephaly Brain Disorder (other than seizures) or Brain Damage Genetic / Chromosomal Disorder AND Angelman Syndrome Cognitive Disability Angina Cardiac Condition Anophthalmia Blind or Severely Visually Impaired Anotia Congenital Abnormality Anoxic Encephalopathy / Brain Syndrome Brain Disorder (other than seizures) or Brain Damage Antiphospholipid Syndrome Immune Deficiency AODA (Alcohol or Other Drug Abuse) Substance-Related Disorder (must verify diagnosis) Aortic Sclerosis Cardiac Condition Aortic Valve Disease / Disorder / Stenosis Cardiac Condition Aperts Syndrome Genetic / Chromosomal Disorder Aphasia (Expressive or Receptive) Neuromuscular Disorder Skin Disease (if severe) OR Include in Note Section, no Aplasia Cutis Congenita Diagnosis checked Aplastic Anemia Anemia (e.g., Sickle Cell, Fanconi’s) Apnea or Sleep Apnea Respiratory Condition (other than Asthma) Apraxia / Apraxia of Speech Neuromuscular Disorder Aqueductal Stenosis Brain Disorder (other than seizures) or Brain Damage Arachnoid Cyst Brain Disorder (other than seizures) or Brain Damage

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 3 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Brain Disorder (other than siezures) or Brain Damage (if Arachnoid Cysts cysts are in the brain), OR Include in Note Section, no Diagnosis checked Argininosuccinate Lyase Deficiency Metabolic Disorder Arhinia Congenital Abnormality Arnold Chiari Malformation Brain Disorder (other than seizures) or Brain Damage Arrhythmia Cardiac Condition Arthogryposis (Multiplex) Limb Missing, Severe Limb Abnormality, Arthrogryposis Articulation Disorder Include in Note Section, no Diagnosis checked Aspiration Include in Note Section, no Diagnosis checked Aspiration Pneumonia Infection – Current or Recurrent Infection Asplenia Include in Note Section, no Diagnosis checked Astigmatism Include in Note Section, no Diagnosis checked Brain Disorder (other than seizures) or Brain Damage AND Astrocytoma Cancer Ataxia Neuromuscular Disorder Ataxic Gait Neuromuscular Disorder Atelectasis Respiratory Condition (other than Asthma) Athetoid Cerebral Palsy Cerebral Palsy Atlantoaxial Instability (AAI) Include in Note Section, no Diagnosis checked Atonic Bladder Genitourinary System Disorder Atonic Colon Digestive System Disorder Atonic Diplegia Neuromuscular Disorder Skin Disease (if severe) OR Atopic Dermatitis Include in Note Section, no Diagnosis checked Atrial Fib / Fibrillation (A-Fib) Cardiac Condition Atrial Septal Defect Cardiac Condition Atrioventricular Canal / Endocardial Cushion Defect Cardiac Condition Atr-X Syndrome Genetic / Chromosomal Disorder Post-Traumatic Stress or Acute Stress Disorder OR Attachment Disorder Reactive Attachment Disorder Auditory Comprehension Delays Neuromuscular Disorder Auditory Neuropathy Neuromuscular Disorder Auditory Processing Disorder Sensory Disorder (other than Blind or Deaf) Autistic Tendencies Include in Note Section, no Diagnosis checked Autoimmune Anti-MBP Immune Deficiency Auto-Immune Disorder Immune Deficiency Immune Deficiency AND Autoimmune Enteropathy Digestive System Disorder Autoimmune Lymphoproliferative Syndrome Immune Deficiency (ALPS) Autonomic Dysreflexia / Hyper-Reflexia Neuromuscular Disorder Autonomic Nervous System Dysfunction Neuromuscular Disorder Autonomic Neuropathy Neuromuscular Disorder AV Canal Defect Cardiac Condition Avoidance Personality Traits Personality Disorder (must verify diagnosis) Bacterial Meningitis Infection – Current or Recurrent Infection Balanced Chromosome Translocation Include in Note Section, no Diagnosis checked Balanced Translocation Karotype 46xy Include in Note Section, no Diagnosis checked Skin Disease (if severe) OR Balanitis Xerotica Obliterans Include in Note Section, no Diagnosis checked

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 4 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Seizure Disorder (if present) OR Band Heterotopia Include in Note Section, no Diagnosis checked Bannayan Riley Ruvalcaba Syndrome Genetic / Chromosomal Disorder Basal Cell Carcinoma Cancer Cancer (if diagnosed as Basal Cell Carcinoma) OR Basal Cell Nevus Syndrome Include in Note Section, no Diagnosis checked Basement Membrane Disease Include in Note Section, no Diagnosis checked Bathrocephaly Include in Note Section, no Diagnosis checked Batten-Spielmeyer-Vogt Disease Brain Disorder (other than seizures) or Brain Damage Becker’s Syndrome Muscular Dystrophy Beckwith Wiedemann Syndrome Genetic / Chromosomal Disorder Bedsore Wound, Burn, Bedsore, Pressure Ulcer Disruptive Behavior Disorder (if true) OR Behavioral Disorder Include in Note Section, no Diagnosis checked Behavioral Feeding Disorder Include in Note Section, no Diagnosis checked Behavioral Problems Include in Note Section, no Diagnosis checked Bell’s Palsy Neuromuscular Disorder Benign Congenital Hypotonia Musculoskeletal Disorder Cardiac Condition (if symptomatic) OR Bicuspid Aortic Valve Congenital Abnormality Blind or Severely Visually Impaired (if child is blind) OR Bilateral Cataracts Include in Note Section, no Diagnosis checked Musculoskeletal Disorder (if severe) OR Bilateral Coxa Valga Include in Note Section, no Diagnosis checked Bilateral Equinovarus Include in Note Section, no Diagnosis checked Bilateral Hip Dislocation Musculoskeletal Disorder Bilateral periventricular nodular heterotopia Seizure Disorder (if present) OR (BPNH) Include in Note Section, no Diagnosis checked Biliary Atresia / Duct Obstruction Digestive System Disorder Bipolar Disorder, Rapid Cycling Bi-Polar Disorder (must verify diagnosis) Birthmarks Include in Note Section, no Diagnosis checked Bladder Cancer Cancer Infection – Current or Recurrent Infection (if chronic and Bladder Infection severe) OR Include in Note Section, no Diagnosis checked Bladder Reflux Genitourinary System Disorder Bleeding Disorder Hemophilia / Other Blood Disorder Bleeding Ulcer Digestive System Disorder Blepharoptosis Include in Note Section, no Diagnosis checked Blocked Tear Duct Include in Note Section, no Diagnosis checked Infection – Current or Recurrent Infection (if chronic and Blood Infection severe) OR Include in Note Section, no Diagnosis checked Musculoskeletal Disorder (if severe) OR Blount Disease Include in Note Section, no Diagnosis checked Genetic / Chromosomal Disorder AND Bohring-Opitz Syndrome Cognitive Disability Bone Dysplasia Musculoskeletal Disorder Bone Marrow Suppression Immune Deficiency Bor Syndrome Genetic / Chromosomal Disorder Developmental Delay (if valid FSIQ under 76) OR Include Borderline Intellectual Functioning in Note Section, no Diagnosis checked Borderline Personality Personality Disorder (must verify diagnosis) Born Without A Vestibular System Congenital Abnormality

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 5 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Bowel Impaction / Obstruction / Resection Digestive System Disorder Brachial Plexus Paralysis / Injury Neuromuscular Disorder Bradycardia Cardiac Condition Brain Anoxia Brain Disorder (other than seizures) or Brain Damage Brain Arteriovenous Malformations (AVM) Brain Disorder (other than seizures) or Brain Damage Brain Bleed – Grade 3, Grade 4 Brain Disorder (other than seizures) or Brain Damage Brain Cysts Brain Disorder (other than seizures) or Brain Damage Brain Dead Brain Disorder (other than seizures) or Brain Damage Brain Hemorrhage Brain Disorder (other than seizures) or Brain Damage Brain Injury Brain Injury—Traumatic (per statutory definition of TBI) Brain Disorder (other than seizures) or Brain Damage AND Brain Stem Glioma Cancer Brain Tumor / Brain Stem Tumor Brain Disorder (other than seizures) or Brain Damage Branchial Cleft Syndrome (Goldenhar Syndrome) Congenital Abnormality Bridges–Good Syndrome (Chronic Granulomatous Immune Deficiency Disease) (CGD) Broken Ankle Include in Note Section, no Diagnosis checked Bronchial Asthma Asthma Bronchiospasm F1 Respiratory Condition (other than Asthma) Bronchitis Respiratory Condition (other than Asthma) Bronchopneumonia Respiratory Condition (other than Asthma) Bronchopulmonary Dysplasia (BPD) Respiratory Condition (other than Asthma) Anorexia Nervosa, Bulimia, or Other Eating Disorder Bulimia (must verify diagnosis) Bunions Include in Note Section, no Diagnosis checked Burkett’s Lymphoma Cancer Burn Wound, Burn, Bedsore, Pressure Ulcer Caffey Disease Musculoskeletal Disorder Calcaneovalgus Musculoskeletal Disorder Callosum Cranium Syndrome Brain Disorder (other than seizures) or Brain Damage Canavan’s Disease Brain Disorder (other than seizures) or Brain Damage Candida / Candidiasis Infection – Current or Recurrent Infection Carbohydrate-Deficient Glycoprotein Syndrome Metabolic Disorder Carcinoma Cancer Cardiac Arrest Include in Note Section, no Diagnosis checked Cardiac Dysrhythmia Cardiac Condition Cardiofaciocutaneous Syndrome (CFC) Genetic / Chromosomal Disorder Cardiomegaly Cardiac Condition Cardiomyopathy Cardiac Condition Carnitine Deficiency Metabolic Disorder Cat Eye Syndrome Genetic / Chromosomal Disorder Cataplexy Neuromuscular Disorder Blind or Severely Visually Impaired (if child is blind) OR Cataracts Sensory Disorder (other than Blind or Deaf) Celiac Disease Digestive System Disorder Central Auditory Processing Disorder (CAPD) Sensory Disorder (other than Blind or Deaf) Central Core Disease (CCD) Musculoskeletal Disorder Central Core Myopathy Musculoskeletal Disorder Neuromuscular Disorder AND Central Hypoventilation Syndrome (CCHC) Respiratory Condition (other than Asthma) Central Integrative Processing Disorder Sensory Disorder (other than Blind or Deaf) Cerebellar Ataxia Neuromuscular Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 6 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Cerebellum Agenesis Brain Disorder (other than seizures) or Brain Damage Cerebral Aneurysm Brain Disorder (other than seizures) or Brain Damage Cerebral Atrophy Brain Disorder (other than seizures) or Brain Damage Cerebral Dysgenesis Brain Disorder (other than seizures) or Brain Damage Cerebral Emboli / Embolism Cerebral Vascular Accident (CVA) (Pre or Postnatal) Cerebral Hypoplasia Brain Disorder (other than seizures) or Brain Damage Cerebral Infarct Cerebral Vascular Accident (CVA) (Pre or Postnatal) Cerebral Salt-Wasting Syndrome (CSWS) Endocrine Disorder (not Diabetes) Cerebral Thrombosis Cerebral Vascular Accident (CVA) (Pre or Postnatal) Blind or Severely Visually Impaired (if child is blind) OR Cerebral Visual Impairment Include in Note Section no Diagnosis checked Cerebrocostomandibular Syndrome (CCM or Musculoskeletal Disorder CCMS) Charcot-Marie Tooth Disease Neuromuscular Disorder Cognitive Disability AND Genetic / Chromosomal Disorder AND CHARGE Syndrome Digestive System Disorder (if present) AND Genitourinary System Disorder (if present) Childhood Disintegrative Disorder (CDD) Pervasive Developmental Disorder (must verify diagnosis) Choanal Atresia Congenital Abnormality Cholangiosarcoma Cancer Cholecystitis Digestive System Disorder Cholelithiasis Digestive System Disorder Cholesterol, High Include in Note Section, no Diagnosis checked Chondromas Musculoskeletal Disorder Chorea Neuromuscular Disorder Choreoathetosis Neuromuscular Disorder Blind or Severely Visually Impaired (if child is blind) OR Chorioretinitis Include in Note Section, no Diagnosis checked Chromosomal Abnormality Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND Chromosome 13 Ring Syndrome Brain Disorder (other than seizures) or Brain Damage Genetic / Chromosomal Disorder AND Chromosome 22 Ring Developmental Delay Chromosome Deletion Genetic / Chromosomal Disorder Chronic Granulomatous Disease (CGD) Immune Deficiency Chronic Granulomatous Disease (CGD) (Bridges– Immune Deficiency Good Syndrome) Chronic Inflammatory Demyelinating Neuromuscular Disorder Polyradiculoneuropathy (CIDP) Chronic Intestinal Dysmotility (CID) Digestive System Disorder Chronic Lung Disease Respiratory Condition (other than Asthma) Chronic Motor Tic Disorder Neuromuscular Disorder Chronic Severe Pain Neuromuscular Disorder Chylothorax Respiratory Condition (other than Asthma) Cirrhosis Liver Disease (Hepatic Failure, Cirrhosis) Citrullinemia Metabolic Disorder Cleft Palate/ Cleft Lip Congenital Abnormality Digestive System Disorder (if stomach, intestines, or anus) Cloacal Exstrophy OR Genitourinary System Disorder (if bladder) OR Musculoskeletal Disorder (if spinal) Clostridium Include in Note Section, no Diagnosis checked

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 7 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Clostridium Difficile Infection – Current or Recurrent Infection Club Foot Congenital Abnormality Coagulation Defects Hemophilia / Other Blood Disorder Coarctation of the Aorta Cardiac Condition Cocaine Exposure, Cocaine Withdrawal Include in Note Section, no Diagnosis checked Cognitive Affective Disorder Brain Disorder (other than seizures) or Brain Damage Cognitive Delays Developmental Delay Cognitive Disorder-NOS Developmental Delay Cognitive Impairment Cognitive Disability Cold Include in Note Section, no Diagnosis checked Colitis Digestive System Disorder Blind or Severely Visually Impaired (if child is blind) OR Colobomata / Coloboma Include in Note Section, no Diagnosis checked Colon Disease Digestive System Disorder Colonic Atresia Digestive System Disorder Colpolocephaly Brain Disorder (other than seizures) or Brain Damage Coma / Comatose Brain Disorder (other than seizures) or Brain Damage Combined Immune Deficiency Immune Deficiency Communication Disorder Neuromuscular Disorder Deaf or Severely Hearing Impaired (if child is deaf), OR Conductive Hearing Loss Sensory Disorder (other than Blind or Deaf) Congenital Abnormality AND Congenital Anomaly Of Left Microtia Ith Atresia Neuromuscular Disorder (if causes hearing loss) Congenital Central Hypoventilation Syndrome Neuromuscular Disorder (CCHS) Congenital Cystic Adenomatoid Malformation Congenital Abnormality (CCAM) Congenital disorder of glycosylation (CDG) Metabolic Disorder Congenital Fiber-Type Disproportion (CFTD) Neuromuscular Disorder Congenital Heart Defect Cardiac Condition Congenital Hydantoin Syndrome Musculoskeletal Disorder Congenital Lymphedema Congenital Abnormality Congenital Volvulus Digestive System Disorder Congestive Heart Failure (CHF) Cardiac Condition Conjunctivitis Infection – Current or Recurrent Infection Connective Tissue Disorder (Fibulin 4) Immune Deficiency Constipation Include in Note Section, no Diagnosis checked Constricted Esophagus Digestive System Disorder Blind or Severely Visually Impaired (if child is blind) OR Convergence Exotropia Include in Note Section, no Diagnosis checked Blind or Severely Visually Impaired (if child is blind) OR Convergence Insufficiency Include in Note Section, no Diagnosis checked Cornelia de Lange Syndrome Cognitive Disability Cortical Blindness Blind or Severely Visually Impaired Cortical Dysplasia Seizure Disorder Cortisol Deficiency / Dependent Endocrine Disorder (not Diabetes) Coxsackie Virus Infection – Current or Recurrent Infection Craniofacial Dysplasia Musculoskeletal Disorder Craniosynostosis (Sagital Suture Fused) Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND Cri Du Chat Syndrome (5p deletion) (CDCS) Cognitive Disability Crigler-Najjar Syndrome Metabolic Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 8 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Crohn’s Disease Digestive System Disorder Cross Eyed Include in Note Section, no Diagnosis checked Crouzon Syndrome Musculoskeletal Disorder Cryptorchidism Include in Note Section, no Diagnosis checked Curtis Marmorata Congenita Congenital Abnormality Cushing’s Syndrome Endocrine Disorder (not Diabetes) Cyclic Vomiting Disorder / Syndrome (CVS) Digestive System Disorder Cyclothymia Bi-Polar Disorder (must verify diagnosis) Cystic Encephalomalacia Brain Disorder (other than seizures) or Brain Damage Cystic Hygroma Include in Note Section, no Diagnosis checked Cystic Lung Disease Respiratory Condition (other than Asthma) Cystinosis Metabolic Disorder Cystinuria Metabolic Disorder Infection – Current or Recurrent Infection (if congenital) Cytomegalovirus (CMV) OR Include in Note Section, no Diagnosis checked Damp Syndrome Metabolic Disorder Dandy-Walker Syndrome / Malformation / Complex Brain Disorder (other than seizures) or Brain Damage (DWS) Dandy-Walker Variant Brain Disorder (other than seizures) or Brain Damage de Lange Syndrome (Cornelia de Lange Syndrome) Cognitive Disability Genetic / Chromosomal Disorder AND De Novo 46xx.Del(6)(Q25.3) Karotype Developmental Delay Decubitus / Decubiti Wound, Burn, Bedsore, Pressure Ulcer Deep Venous Thrombosis Hemophilia / Other Blood Disorder Deficiency – Thiamine, Niacin, Riboflavirn, Biotin, Pantothenic Acid, Iron, Iodine, Fluorine, Zinc, Nutritional Imbalance (e.g., Malnutrition, Vitamin Chromoium, Selenium, Manganese, Molybdenum, Deficiencies) Copper, Carnitine, B-12, B-6 Etc. Degenerative Arthritis Arthritis Degenerative Joint Disease Musculoskeletal Disorder Delayed Milestones Include in Note Section, no Diagnosis checked Delayed Myelination Neuromuscular Disorder Delayed Occular Development Include in Note Section, no Diagnosis checked Delayed Puberty Include in Note Section, no Diagnosis checked Genetic / Chromosomal Disorder AND Deletion of the 5th Chromosome Cognitive Disability Delusions of Persecution Schizophrenia or Other Psychotic Disorder Dementia Brain Disorder (other than seizures) or Brain Damage Dental Abnormalities Include in Note Section, no Diagnosis checked Dental Caries Include in Note Section, no Diagnosis checked Dental Disease Infection – Current or Recurrent Infection Dentogenesis Imperfecta Genetic / Chromosomal Disorder Dependent Personality Disorder Personality Disorder (must verify diagnosis) Depressive Disorder Depression (must verify diagnosis) Dermatillomania Impulse-Control Disorder (must verify diagnosis) Dermatitis Infection – Current or Recurrent Infection Dermatological Rash Include in Note Section, no Diagnosis checked Dermatomyositis Immune Deficiency Developmental Apraxia Neuromuscular Disorder Developmental Arithmetic Disorder Include in Note Section, no Diagnosis checked Developmental Coordination Disorder Developmental Delay Developmental Dysplasia of Hip Musculoskeletal Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 9 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Developmental Language Disorder Neuromuscular Disorder Developmental Verbal Apraxia Neuromuscular Disorder Dextrocardia Congenital Abnormality Diabetes (Type 1) Diabetes Diabetes Insipidus Dehydration / Fluid & Electrolyte Imbalance Diabetes Juvenile Diabetes Diabetes Mellitus Diabetes Diabetic Neuropathy Neuromuscular Disorder Diabetic Peripheral Neuropathy Neuromuscular Disorder Diamond Blackfan Anemia Anemia (e.g., Sickle Cell, Fanconi’s) Diaphragmatic Hernia Respiratory Condition (other than Asthma) Diarrhea Include in Note Section, no Diagnosis checked Diffuse Hypotonia Neuromuscular Disorder Digeorge Syndrome Genetic / Chromosomal Disorder Digestive Disorder Digestive System Disorder Digestive Neoplasm Cancer Diminished Hearing Include in Note Section, no Diagnosis checked Diplopia (Double Vision) Include in Note Section, no Diagnosis checked Disassociative Identity Disorder Dissociative Disorder Disedidict Dyslexia Include in Note Section, no Diagnosis checked Disorder of Infancy, Childhood or Adolescence Include in Note Section, no Diagnosis checked NOS Disorder Of Written Expression Include in Note Section, no Diagnosis checked Disruptive Behavior Disorder Disruptive Behavior Disorder (must verify diagnosis) Diverticulosis / Diverticulitis Digestive System Disorder Dongenital Disorder Of Glycosylation (CDG) Metabolic Disorder Dopa-Responsive Dystonia (DRD) Neuromuscular Disorder Drug Dependency Substance-Related Disorder (must verify diagnosis) Blind or Severely Visually Impaired (if child is blind) OR Duane’s Syndrome Include in Note Section, no Diagnosis checked Dubowitz Syndrome Musculoskeletal Disorder Duchenne’s Muscular Dystrophy Muscular Dystrophy Dumping Syndrome Digestive System Disorder AND Nutritional Imbalance Duodenal Disease / Atresia Digestive System Disorder Dwarfism Musculoskeletal Disorder Dysarthria Neuromuscular Disorder Dysautonomia Disorder/Syndrome Neuromuscular Disorder Dyscalculia Include in Note Section, no Diagnosis checked Dysgraphia Include in Note Section, no Diagnosis checked Dyslexia Include in Note Section, no Diagnosis checked Dysomnia Include in Note Section, no Diagnosis checked Dyspepsia Digestive System Disorder Dysphagia Digestive System Disorder Dysphasia Neuromuscular Disorder Dysplastic Kidney Genitourinary System Disorder Dyspnea Respiratory Condition (other than Asthma) Dyspraxia Neuromuscular Disorder Dysthymic Disorder Dysthymic Disorder (must verify diagnosis) Dystonia Neuromuscular Disorder E Coli Infection – Current or Recurrent Infection Eagle Barrett Syndrome (Prune Belly) Genitourinary System Disorder Ear Infections Infection – Current or Recurrent Infection

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 10 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Anorexia Nervosa, Bulimia, or Other Eating Disorder Eating Disorder (must verify diagnosis) Skin Disease (if severe) OR Ectodermal Dysplasia Include in Note Section, no Diagnosis checked Skin Disease (if severe) OR Eczema Include in Note Section, no Diagnosis checked Skin Disease (if severe) OR Eczematoid Dermatitis Include in Note Section, no Diagnosis checked Educational Diagnosis of ______Include in Note Section, no Diagnosis checked Genetic / Chromosomal Disorder AND Edwards Syndrome (Trisomy 18 Syndrome) Cognitive Disability Ehlers-Danlos Syndrome Musculoskeletal Disorder Electrolyte Imbalance Dehydration / Fluid & Electrolyte Imbalance Genetic / Chromosomal Disorder AND Emanuel Syndrome (Trisomy 22) Cognitive Disability Emotional Disorder / Disturbance Personality Disorder Emphysema Respiratory Condition (other than Asthma) Empyema Include in Note Section, no Diagnosis checked Brain Disorder (other than seizures) or Brain Damage AND Encephalitis Infection – Current or Recurrent Infection Encephalocele Brain Disorder (other than seizures) or Brain Damage Encephalomalacia Brain Disorder (other than seizures) or Brain Damage Encephalopathy Brain Disorder (other than seizures) or Brain Damage Encopresis Include in Note Section, no Diagnosis checked Endocardial Cushion Defect Cardiac Condition Endocarditis Cardiac Condition Enlarged Bladder Genitourinary System Disorder Enlarged Heart Cardiac Condition Enteritis Digestive System Disorder Enuresis Include in Note Section, no Diagnosis checked Eosinophilic Esophagitis Digestive System Disorder Eosinophilic Gastroenteritis Digestive System Disorder Epidermolysis Bullosa / Bulbosa (EB, EBS) Skin Disease Epigastric Pain Include in Note Section, no Diagnosis checked Epigastric Reflux Symptoms Include in Note Section, no Diagnosis checked Epilepsy Seizure Disorder Epileptic Encephalopathy Seizure Disorder Epispadias Congenital Abnormality Epstien Barr Virus (EBV) Infection – Current or Recurrent Infection Erb’s Palsy Neuromuscular Disorder Escobar Syndrome Limb Missing, Severe Limb Abnormality, Arthrogryposis Esophageal Erosion / Ulcer Digestive System Disorder Esophageal Fistula / Stricture Digestive System Disorder Esophageal Reflux Disease Digestive System Disorder Esophageal Varicies Digestive System Disorder Esophagitis Digestive System Disorder Blind or Severely Visually Impaired (if child is blind) OR Esotropia Include in Note Section, no Diagnosis checked ESRD (End Stage Renal Disease) Renal Failure or other Kidney Disease Ethmoid Sinusitis Infection – Current or Recurrent Infection ETOH (Ethanol) Abuse / Withdrawal Substance-Related Disorder (must verify diagnosis) Eustachian Tube Dysfunction Include in Note Section, no Diagnosis checked

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 11 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Ewing’s Sarcoma / Tumor Cancer Excessive Daytime Sleepiness (EDS) Neuromuscular Disorder Exhibitionism Sexual or Gender Identity Disorder Exotropia Include in Note Section, no Diagnosis checked Explosive Disorder Conduct Disorder (must verify diagnosis) Explosive Personality Disorder Personality Disorder (must verify diagnosis) Expressive Aphasia Neuromuscular Disorder Expressive or Receptive Language Disorder / Delay Neuromuscular Disorder Exstrophy of the Bladder Congenital Abnormality Extreme Tactile Defensive Sensory Disorder (other than Blind or Deaf) Face Blindness Brain Disorder (other than seizures) or Brain Damage Factitious Disorder Somatoform Disorder Factor H Deficiency Hemophilia / Other Blood Disorder Factor V Leiden Blood Disorder Hemophilia / Other Blood Disorder Far Sighted Include in Note Section, no Diagnosis checked FAS (Fetal Alcohol Syndrome) Fetal Alcohol Syndrome / Effect Fatty Acid Oxidation Syndrome Metabolic Disorder Febrile Seizures Include in Note Section, no Diagnosis checked Feeding Difficulties Include in Note Section, no Diagnosis checked Femoral Anteversion Musculoskeletal Disorder Fetal Alcohol Spectrum Disorder (FASD) Fetal Alcohol Syndrome / Effect Fetal Dilantin Syndrome Musculoskeletal Disorder AND Congenital Abnormality Fetal Hydantoin Syndrome Musculoskeletal Disorder AND Congenital Abnormality Fetal Valproate / Valproic Syndrome Musculoskeletal Disorder AND Congenital Abnormality Fetishism Sexual or Gender Identity Disorder Genetic / Chromosomal Disorder AND Fg Syndrome (Opitz-Kaveggia) Cognitive Disability Fibromyalgia Syndrome Neuromuscular Disorder Fibrosarcoma Cancer Fibrous Dysplasia Musculoskeletal Disorder Genetic / Chromosomal Disorder AND Cognitive Filippi Syndrome Disability Fine Motor Delay Neuromuscular Disorder Flat-Footed Include in Note Section, no Diagnosis checked Flexion Contractures Contracture / Connective Tissue Disorder Floating Harbor Syndrome Musculoskeletal Disorder AND Neuromuscular Disorder Flynn-Aird Syndrome Neuromuscular Disorder Skin Disease (if severe) OR Focal Dermal Hypoplasia (FDH) Include in Note Section, no Diagnosis checked Folliculitis Include in Note Section, no Diagnosis checked Fracture Include in Note Section, no Diagnosis checked Genetic / Chromosomal Disorder AND Fragile X Syndrome Cognitive Disability Franconi’s Anemia, Disease, or Syndrome Anemia (e.g., Sickle Cell, Fanconi’s) Freeman-Sheldon Syndrome Limb Missing, Severe Limb Abnormality, Arthrogryposis Friedrich’s Ataxia Neuromuscular Disorder Frotteurism Sexual or Gender Identity Disorder Frozen Shoulder Musculoskeletal Disorder Fungal Lung Disease Respiratory Condition (other than Asthma) Anemia, (e.g., Sickle Cell, Fanconi’s) (if present) OR G6pd Deficiency Include in Note Section, no Diagnosis checked Galactosemia Metabolic Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 12 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Gallstones Include in Note Section, no Diagnosis checked Gangliosidosis Metabolic Disorder AND Cognitive Disability Gangrene Infection – Current or Recurrent Infection Gastric Erosion / Distress / Bleed Digestive System Disorder Gastric Esophageal Reflux Digestive System Disorder Gastric Outlet Obstruction / Syndrome Digestive System Disorder Gastric Ulcer / Disease Digestive System Disorder Gastritis Digestive System Disorder Gastroduodenitis Digestive System Disorder Gastroenteritis Digestive System Disorder Gastroentero Fistula Digestive System Disorder Gastroesophageal Reflux (GE Reflux, GER, GERD) Digestive System Disorder Gastroesophagitis Digestive System Disorder Gastrointestinal Bleed / Hemorrhage Digestive System Disorder Gastrointestinal Disorder Digestive System Disorder Gastroparesis Digestive System Disorder Gastroschisis Digestive System Disorder Gaucher’s Disease Metabolic Disorder GE Reflux (Gastroesophygeal Reflux) Digestive System Disorder Gender Identity Disorder (GDI) Sexual or Gender Identity Disorder Genetic Disease of Unknown Diagnosis Genetic / Chromosomal Disorder Genital Herpes Infection – Current or Recurrent Infection GER (Gastroesophygeal Reflux) Digestive System Disorder GERD (Gastroesophageal Reflux Disorder) Digestive System Disorder GI Bleed / Reflux Digestive System Disorder Gilberts Syndrome Liver Disease (Hepatic Failure, Cirrhosis) Genetic / Chromosomal Disorder AND Gillespie Syndrome Neuromuscular Disorder Blind or Severely Visually Impaired (if child is blind) OR Glaucoma Sensory Disorder (other than Blind or Deaf) Gliosis Neuromuscular Disorder Global Delays Developmental Delay Global Hypotonia Neuromuscular Disorder Globoid Cell Leukodystrophy Metabolic Disorder AND Cognitive Disability Glomerulonephritis Renal Failure or other Kidney Disease Glucose Transporter Deficiency Syndrome (Glut- Neuromuscular Disorder DS) Glutaric Acidemia (GA) Metabolic Disorder Digestive System Disorder (if results in Celiac Disease) Gluten Sensitivity (GS) OR Allergy Glycogen Storage Metabolic Disorder Goiter Endocrine Disorder (not Diabetes) Goldenhar Syndrome Congenital Abnormality Goltz Syndrome/ Goltz-Gorlin Syndrome Skin Disease Cancer (if diagnosed as Basal Cell Carcinoma) OR Gorlin Syndrome Include in Note Section, no Diagnosis checked Gouty Arthritis Arthritis Graft vs Host Disease (GVHD) Immune Deficiency Immune Deficiency AND Graves Disease Endocrine Disorder (not Diabetes) Gross Motor Delay Neuromuscular Disorder Growth Hormone Deficiency Endocrine Disorder (not Diabetes)

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 13 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Guanosine Triphosphate Cyclohydrolase I Metabolic Disorder Deficiency (GTPCH) Guillian-Barre Syndrome Neuromuscular Disorder Gum Disease Include in Note Section, no Diagnosis checked GVHD (Graft vs Host Disease) Immune Deficiency Hallermann-Streiff Syndrome Musculoskeletal Disorder Hallervorden-Spatz Disease Neuromuscular Disorder Hallux Varus Include in Note Section, no Diagnosis checked Hashimoto's Thyroiditis Immune Deficiency Head Injury Brain Injury—Traumatic (per statutory definition of TBI) Headaches Include in Note Section, no Diagnosis checked Hearing Deficit, Partial Sensory Disorder (other than Blind or Deaf) Deaf or Severely Hearing Impaired (if child is deaf), OR Hearing Impairment Sensory Disorder (other than Blind or Deaf) Deaf or Severely Hearing Impaired (if child is deaf), OR Hearing Loss Sensory Disorder (other than Blind or Deaf) Heart Disease / Disorder / Defect Cardiac Condition Heart Murmur Include in Note Section, no Diagnosis checked Heart Transplant Cardiac Condition Heller's Syndrome Pervasive Developmental Disorder (must verify diagnosis) Hemangioma Include in Note Section, no Diagnosis checked Hematuria Genitourinary System Disorder Blind or Severely Visually Impaired (if child is blind) OR Hemianopsia Include in Note Section, no Diagnosis checked Hemifacial Microsomia Syndrome Musculoskeletal Disorder Hemiparesis Paralysis, Other than Spinal Cord Injury Hemiplegia Paralysis, Other than Spinal Cord Injury Hemivertebra Musculoskeletal Disorder Hemodialysis Renal Failure or other Kidney Disease Hemolytic Anemia Hemophilia / Other Blood Disorder Hemolytic Uremic Syndrome (HUS) Renal Failure or other Kidney Disease Hemophilia Hemophilia / Other Blood Disorder Hemorrhage, Subarachnoid Cerebral Vascular Accident (CVA) (Pre or Postnatal) Hemorrhagic Gastritis Digestive System Disorder Hepatic Failure Liver Disease (Hepatic Failure, Cirrhosis) Hepatitis Liver Disease (Hepatic Failure, Cirrhosis) Hepatoblastoma Cancer Hereditary Spherocytosis Hemophilia / Other Blood Disorder Hermangiomas Include in Note Section, no Diagnosis checked Hernia Digestive System Disorder Herpes Simplex Infection – Current or Recurrent Infection Herpes Zoster Infection – Current or Recurrent Infection Heterotaxy Syndrome Congenital Abnormality Heterotropia (Strabismus) Include in Note Section, no Diagnosis checked Hidden Penis Include in Note Section, no Diagnosis checked High Blood Pressure Include in Note Section, no Diagnosis checked High Lead Level Include in Note Section, no Diagnosis checked High Levels of Mercury Include in Note Section, no Diagnosis checked High Myopia Include in Note Section, no Diagnosis checked High Palate Include in Note Section, no Diagnosis checked High Triglycerides Include in Note Section, no Diagnosis checked Hinman Syndrome Genitourinary System Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 14 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Hip Dislocation / Dysplasia Musculoskeletal Disorder Hirschsprung's Disease Digestive System Disorder Histrionic personality disorder (HPD) Personality Disorder (must verify diagnosis) Immune Deficiency (Do not include in notes due to HIV Positive confidentiality) Hodgkin’s Disease Cancer Deaf or Severely Hearing Impaired (if child is deaf), OR HOH (Hard of Hearing) Sensory Disorder (other than Blind or Deaf) Cardiac Condition OR Hole In Heart Include in Note Section, no Diagnosis checked (if repaired) Holoprosencepcephaly Brain Disorder (other than seizures) or Brain Damage Horner's Syndrome Neuromuscular Disorder Immune Deficiency (Do not include in notes due to Human Immuno Virus (HIV) confidentiality) Hunter / Hurler’s Syndrome (MPS I or II) Metabolic Disorder Huntington’s Chorea / Disease Brain Disorder (other than seizures) or Brain Damage Hydranencephaly Brain Disorder (other than seizures) or Brain Damage Hydrocephalus Brain Disorder (other than seizures) or Brain Damage Hydronephrosis Renal Failure or other Kidney Disease Hyperactivity Include in Note Section, no Diagnosis checked Hyperacusis Sensory Disorder (other than Blind or Deaf) Hypercalcemia Include in Note Section, no Diagnosis checked Hypercholesterolemia Include in Note Section, no Diagnosis checked Hyperekplexia Neuromuscular Disorder Hyperextensive Mobility Syndrome Musculoskeletal Disorder Hyperglycemia Diabetes Hyperinsulinemia Endocrine Disorder (not diabetes) Hyperkalemia Dehydration / Fluid & Electrolyte Imbalance Hyperkeratosis Skin Disease Attention-Deficit Disorder, Attention-Deficit Hyperactivity Hyperkinesis Disorder (must verify diagnosis) Hyperkinetic Movement Disorder Neuromuscular Disorder Hyperlexia Include in Note Section, no Diagnosis checked Hyperlipidemia Include in Note Section, no Diagnosis checked Hypernatremia Dehydration / Fluid & Electrolyte Imbalance Hyperopia (with or without Astigmatism) Include in Note Section, no Diagnosis checked Hypersplenism Hemophilia / Other Blood Disorder Hypertension Include in Note Section, no Diagnosis checked Hyperthyroidism Endocrine Disorder (not Diabetes) Hypertonic Muscles Neuromuscular Disorder Hypertriglyceridemia Include in Note Section, no Diagnosis checked Hypertrophic Cardiomyopathy (HCM) Cardiac Condition Hyperuricemia Include in Note Section, no Diagnosis checked Hypocalcemia Dehydration / Fluid & Electrolyte Imbalance Hypochondroplasia Musculoskeletal Disorder Hypoglycemia Metabolic Disorder Hypogonadism Endocrine Disorder (not Diabetes) Hypohidrotic Ectodermal Dysplasia Skin Disease Hypokalemia Dehydration / Fluid & Electrolyte Imbalance Hypomanic Include in Note Section, no Diagnosis checked Hypomelanosis of Ito Skin Disease Hyponatremia Dehydration / Fluid & Electrolyte Imbalance

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 15 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Hypopituitarism Endocrine Disorder (not Diabetes) Hypoplasia of The Corpus Callosum Brain Disorder (other than seizures) or Brain Damage Hypoplastic Left Heart Syndrome Cardiac Condition Hypoplastic Pituitary Endocrine Disorder (not Diabetes) Hypoplastic Right Ventricle Cardiac Condition Hypopotassemia Dehydration / Fluid & Electrolyte Imbalance Hypospadias Congenital Abnormality Hypotension Include in Note Section, no Diagnosis checked Hypothalamic Obesity Endocrine Disorder (not Diabetes) Hypothyroidism Endocrine Disorder (not Diabetes) Hypotonia Musculoskeletal Disorder Hypoventilation Respiratory Condition (other than Asthma) Hypoxia Respiratory Condition (other than Asthma) Hypoxic Brain Injury Brain Disorder (other than seizures) or Brain Damage Hypoxic Encephalopathy (Secondary To Drowning) Brain Disorder (other than seizures) or Brain Damage Hypoxic Ischemic Encephalopathy Brain Disorder (other than seizures) or Brain Damage Ichthyosis Follicularis Skin Disease Idic 15 Neuromuscular Disorder Idiopathic Short Stature Include in Note Section, no Diagnosis checked Idiopathic Toe Walking Include in Note Section, no Diagnosis checked Idiopathic Tremor Neuromuscular Disorder IgA Nephropathy Renal Failure or other Kidney Disease IGg Deficiency Immune Deficiency Ileal Lymphoid Nodular Hyperplasia Include in Note Section, no Diagnosis checked Ileus Include in Note Section, no Diagnosis checked Respiratory Condition (other than Asthma) (if present) OR Immotile Cilia Syndrome Include in Note Section, no Diagnosis checked Immune Dysfunction Immune Deficiency Immune Mechanism Disorder Immune Deficiency Imperforate Anus Digestive System Disorder Incontinence Include in Note Section, no Diagnosis checked Infantile Spasms Seizure Disorder Infectious Mononucleosis (Mono) Infection – Current or Recurrent Infection Inflammatory Bowel Disease Digestive System Disorder Influenza Infection – Current or Recurrent Infection Inguinal Hernia Digestive System Disorder Insomnia Include in Note Section, no Diagnosis checked Institutional Autism Autism or Autism Spectrum (must verify diagnosis) Insulin Resistance Immune Deficiency Insulin-Dependent Diabetes Mellitus (IDDM) Diabetes Intellectual Disability (previously referred to as Cognitive Disability Mental Retardation) Intermittent Explosive Disorder Conduct Disorder (must verify diagnosis) Intermittent Microhematuria Include in Note Section, no Diagnosis checked Interstitial Cystitis Genitourinary System Disorder Intracranial Bleed / Bleeding Cerebral Vascular Accident (CVA) (Pre or Postnatal) Intracranial Calcification Include in Note Section, no Diagnosis checked Intracranial Hypertension Neuromuscular Disorder Intractable Epilepsy Seizure Disorder Intrauterine Growth Retardation Congenital Abnormality Intraventricular Hemorrhage Cerebral Vascular Accident (CVA) (Pre or Postnatal) Intussesception Digestive System Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 16 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Inverted X Chromosome Include in Note Section, no Diagnosis checked Inverted Y Chromosome Include in Note Section, no Diagnosis checked Irritable Bowel Disease / Syndrome (IBS) Digestive System Disorder Ischemic Heart Disease Cardiac Condition Isodicentric 15 Neuromuscular Disorder Jacobsen Syndrome (11q deletion) Genetic / Chromosomal Disorder Jaundice Include in Note Section, no Diagnosis checked Joubert Syndrome Brain Disorder (other than seizures) or Brain Damage Juvenile Rheumatoid Arthritis Arthritis Kabuki Syndrome Genetic / Chromosomal Disorder Kallman Syndrome Genetic / Chromosomal Disorder Respiratory Condition (other than Asthma) (if present) OR Kartagener Syndrome (KS) Include in Note Section, no Diagnosis checked Kasabach-Merritt Syndrome Hemophilia / Other Blood Disorder Kawasaki Disease Cardiac Condition Kearns Sayre Syndrome Genetic / Chromosomal Disorder Kernicterus Brain Disorder (other than seizures) or Brain Damage Ketoacidosis Metabolic Disorder Kidney Tube Obstruction Renal Failure or other Kidney Disease Kidney Reflux Renal Failure or other Kidney Disease Kidney Stone Include in Note Section, no Diagnosis checked Kleine Levin Syndrome (KLS) Neuromuscular Disorder Klinefelter Syndrome (47, XXY) Genetic / Chromosomal Disorder Klippel-Trenaunay Syndrome (K-T) Congenital Abnormality Kluver-Bucy Syndrome Brain Disorder (other than seizures) or Brain Damage Koolen De Vries Syndrome Genetic/Chromosomal Disorder Krabbe’s Disease Metabolic Disorder AND Cognitive Disability Kyphosis Musculoskeletal Disorder Lactose Intollerance Include in Note Section, no Diagnosis checked Lamellar Ichthyosis (LI) Skin Disease Neuromuscular Disorder AND Landau-Kleffner Syndrome Seizure Disorder (if present) Genetic / Chromosomal Disorder AND Langer-Giedion Syndrome Musculoskeletal Disorder Langerhans Cell Histiocytosis (LCH) Hemophilia / Other Blood Disorder Language Based Learning Disability Include in Note Section, no Diagnosis checked Language Disorder / Delay Neuromuscular Disorder Larsen Syndrome Genetic / Chromosomal Disorder Laryngomalacia Include in Note Section, no Diagnosis checked Laryngotracheal Anomaly Congenital Abnormality Latex Allergy, Severe Allergy Lazy Eye Include in Note Section, no Diagnosis checked Lead Posioning (Plumbism) Include in Note Section, no Diagnosis checked Learning Delays / Disability / Disorder Include in Note Section, no Diagnosis checked Learning Disorder (Non-Verbal) Include in Note Section, no Diagnosis checked Leber’s Congenital Amaurosis Blind or Severely Visually Impaired Legally Blind Blind or Severely Visually Impaired Legg-Calve Perthes Disease Musculoskeletal Disorder Lennox-Gastaut Syndrome Seizure Disorder Blind or Severely Visually Impaired (if child is blind) OR Lenz Microphthalmia Syndrome Include in Note Section, no Diagnosis checked Leukemia Cancer

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 17 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Leukodystrophy Brain Disorder (other than seizures) or Brain Damage Leukoencephalopathy Brain Disorder (other than seizures) or Brain Damage Leukomalacia Brain Disorder (other than seizures) or Brain Damage Limb Girdle Syndrome Muscular Dystrophy Limited Tongue Movement Include in Note Section, no Diagnosis checked Linear Nevus Sebaceous Syndrome Neuromuscular Disorder Lissencephaly Brain Disorder (other than seizures) or Brain Damage Liver Necrosis Liver Disease (Hepatic Failure, Cirrhosis) Brain Disorder (other than seizures) or Brain Damage (if Lobar Holoprosencephaly present) OR Include in Note Section, no Diagnosis checked Lordosis Musculoskeletal Disorder Lou Gehrig’s Disease Multiple Sclerosis or ALS Low ACTH Metabolic Disorder Low Muscle Tone Neuromuscular Disorder Low Testosterone Include in Note Section, no Diagnosis checked Low Thyroid Endocrine Disorder (not Diabetes) Lupus Immune Deficiency Lyme Disease Infection – Current or Recurrent Infection Lymphangioma Congenital Abnormality Lymphangiomatosis Congenital Abnormality AND Cancer (if present) Macrocephaly Developmental Delay Macrocephaly-Capillary Malformation Syndrome Developmental Delay (M-CM) Macroglossia Include in Note Section, no Diagnosis checked Blind or Severely Visually Impaired (if child is blind) OR Macular Degeneration Sensory Disorder (other than Blind or Deaf) Malabsorption Syndrome Digestive System Disorder AND Nutritional Imbalance Malignant Neoplasm Cancer Nutritional Imbalance (e.g., Malnutrition, Vitamin Malnutrition Deficiencies) Mandibular Hypoplasia Include in Note Section, no Diagnosis checked Maple Syrup Urine Disease Metabolic Disorder Marden Walker Syndrome Contractures/ Connective Tissue Disorder Marfan Syndrome Musculoskeletal Disorder MASA Syndrome Cognitive Disability Mastocytosis Include in Note Section, no Diagnosis checked Mathematics Disorder Include in Note Section, no Diagnosis checked Maxillary Sinusitis Infection – Current or Recurrent Infection McCune-Albright Syndrome (MAS) Endocrine Disorder (not Diabetes) Genetic / Chromosomal Disorder AND MECP2 Duplication Syndrome Cognitive Disability Brain Disorder (other than seizures) or Brain Damage AND Medulloblastoma Cancer Megalencephaly Brain Disorder (other than seizures) or Brain Damage Megalencephaly-Cutis Marmorata Telangiectatica Brain Disorder (other than seizures) or Brain Damage Congenita Syndrome (M-CMTC) Meniere’s Disease Sensory Disorder (other than Blind or Deaf) Brain Disorder (other than seizures) or Brain Damage AND Meningitis Infection – Current or Recurrent Infection Meningomyelocele Spina Bifida Mesial Temporal Sclerosis Seizure Disorder Metal Toxicity Include in Note Section, no Diagnosis checked

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 18 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Methicillin Resistant Staphylococcus Aureus Infection – Current or Recurrent Infection (MRSA) Micro Syndrome Cognitive Disability Microcephaly Developmental Delay Microencephaly Developmental Delay Micrognathia Include in Note Section, no Diagnosis checked Blind or Severely Visually Impaired (if child is blind) OR Microphthalmia Include in Note Section, no Diagnosis checked Microscopic Polyangiitis Include in Note Section, no Diagnosis checked Microtia Include in Note Section, no Diagnosis checked Migraines Include in Note Section, no Diagnosis checked Migraines Cephalalgia Include in Note Section, no Diagnosis checked Milk Intolerance Include in Note Section, no Diagnosis checked Missing Left Ventricle Cardiac Condition Mitochondrial Disorder Genetic / Chromosomal Disorder Mitochondrial Myopathy Neuromuscular Disorder Mitochondrial Myopathy, Encephalopathy, Lactic Neuromuscular Disorder AND Acidosis, and Stroke Syndrome (MELAS) Brain Disorder (other than seizures) or Brain Damage Mitral Valve Stenosis or Disease Cardiac Condition Mixed Receptive/Expressive Language Disorder Neuromuscular Disorder Moebius Syndrome Neuromuscular Disorder Mono Virus (Infectious Mononucleosis) Infection – Current or Recurrent Infection Monoamine Neurotransmitter Deficiency Neuromuscular Disorder Monocular Estropia with Amblyopia Include in Note Section, no Diagnosis checked Genetic / Chromosomal Disorder AND Monosomy 20p13 Musculoskeletal Disorder Morbid Obesity Digestive System Disorder Morquio Syndrome Metabolic Disorder Mosaic Down Syndrome Down Syndrome – Mosaic or Translocation Mosaic, Mosaicism Down Syndrome – Mosaic or Translocation Motor Coordination Disorder / Dyspraxia Neuromuscular Disorder Motor Delays Neuromuscular Disorder Motor Planning Delay/Disorder Neuromuscular Disorder Motor-Tic Disorder Neuromuscular Disorder Movement Disorder Include in Note Section, no Diagnosis checked Mowat-Wilson Syndrome Cognitive Disability MRSA (Methicillin Resistant Staphylococcus Infection – Current or Recurrent Infection Aureus) Mucopolysaccharidosis (MPS III) (Sanfilippo Metabolic Disorder AND Cognitive Disability Syndrome) Mullerian Agenesis Include in Note Section, no Diagnosis checked Multicystic Kidney Renal Failure or other Kidney Disease Multi-Organ Metabolic Disease Metabolic Disorder Multiple Body Dysfunction Include in Note Section, no Diagnosis checked Multiple Chemical Sensitivities Allergy Infection – Current or Recurrent Infection (if severe) OR Multiple Ear Infections Include in Note Section, no Diagnosis checked Murmur Include in Note Section, no Diagnosis checked Muscle Incoordination Include in Note Section, no Diagnosis checked Muscle Weakness Disorder Include in Note Section, no Diagnosis checked Mute Neuromuscular Disorder MVP (Mitral Valve Prolapse) Cardiac Condition

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 19 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Myasthenia Gravis Neuromuscular Disorder Myelopathy Neuromuscular Disorder Myeloproliferative Disorder Hemophilia / Other Blood Disorder Myocarditis Cardiac Condition Myoclonus Seizure Disorder Myofascial Pain Syndrome Musculoskeletal Disorder Myopathy Neuromuscular Disorder Myotonic Dystrophy Muscular Dystrophy Nager Syndrome Musculoskeletal Disorder Nail-Patella Renal Syndrome (NPS) Renal Failure or other Kidney Disease Narcolepsy Neuromuscular Disorder Near Drowning Brain Injury—Traumatic (per statutory definition of TBI) Necrotizing Enterocolitis Digestive System Disorder Nemaline Myopathy Neuromuscular Disorder Brain Disorder (other than seizures) or Brain Damage AND Neonatal Meningitis Infection – Current or Recurrent Infection Neoplasm Cancer Nephritis Genitourinary System Disorder Nephrotic Syndrome Genitourinary System Disorder Deaf or Severely Hearing Impaired (if child is deaf), OR Nerve Deafness Sensory Disorder (other than Blind or Deaf) Nerve Palsy Neuromuscular Disorder Nervous Tic Disorder Neuromuscular Disorder Nesidioblastosis Metabolic Disorder Neural Tube Defect Brain Disorder (other than seizures) or Brain Damage Neuralgia Neuromuscular Disorder Neuroblastoma Cancer Neurocognitive Disorder Brain Disorder (other than seizures) or Brain Damage Neurocutanious Melanosis Congenital Abnormality Neurofibromatosis Neuromuscular Disorder Neurogenic Bladder / Bowel Genitourinary System Disorder Neurological Insult Neuromuscular Disorder Neuromuscular Disease Neuromuscular Disorder Neuronal Ceroid Lipofuscinoses (NCL) Neuromuscular Disorder Neuropathy Neuromuscular Disorder Neutropenia Hemophilia / Other Blood Disorder Niemann-Pick Disease Metabolic Disorder No pupils in eyes Blind or Severely Visually Impaired Nocutrnal Enuresis Include in Note Section, no Diagnosis checked Non Allergic Rhinitis Infection – Current or Recurrent Infection Non Verbal Learning Disorder / Disability Include in Note Section, no Diagnosis checked Non-Hodgkins Lymphoblastic Lymphoma Cancer Non-Insulin-Dependent Diabetes (NIDDM) Diabetes Non-Verbal Neuromuscular Disorder Noonan Syndrome Musculoskeletal Disorder Nystagmus Sensory Disorder (other than Blind or Deaf) Digestive System Disorder (if child has Morbid Obesity) Obesity OR Include in Note Section, no Diagnosis checked OBS (Organic Brain Syndrome) Brain Disorder (other than seizures) or Brain Damage Obstructive Urinary Tract Defect Genitourinary System Disorder OCD Obsessive-Compulsive Disorder (must verify diagnosis) Ocular Motor Dysfunction / Syndrome / Apraxia Neuromuscular Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 20 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Oculoauriculovertebral Association Musculoskeletal Disorder Oculocutaneous Albinism Skin Disease ODD Oppositional Defiant Disorder (must verify diagnosis) Ohtahara Syndrome Seizure Disorder OI (Osteogenesis Imperfecta) Musculoskeletal Disorder Oligodendroglioma Cancer Omenn Syndrome Immune Deficiency Omphalocele Digestive System Disorder One Kidney Renal Failure or other Kidney Disease Opitz G/BBB Syndrome Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND Opitz Kaveggia Syndrome (Fg Syndrome) Cognitive Disability Genetic / Chromosomal Disorder AND Opitz Syndrome Cognitive Disability Genetic / Chromosomal Disorder AND Opitz-Trigonocephaly (C Syndrome) Cognitive Disability Opsoclonus-Myoclonus Syndrome (OMS) Neuromuscular Disorder Optic Glioma Cancer Blind or Severely Visually Impaired (if child is blind) OR Optic Hypoplasia Include in Note Section, no Diagnosis checked Blind or Severely Visually Impaired (if child is blind) OR Optic Nerve Atrophy Include in Note Section, no Diagnosis checked Blind or Severely Visually Impaired (if child is blind) OR Optic Nerve Hypoplasia Sensory Disorder (other than Blind or Deaf) Post-Traumatic Stress or Acute Stress Disorder OR Optimum Attachment Disorder Reactive Attachment Disorder Oral Facial Digital Syndrome (OFD) Musculoskeletal Disorder Oral Motor Apraxia Neuromuscular Disorder Oral Thrush Include in Note Section, no Diagnosis checked Oral Ulcers Include in Note Section, no Diagnosis checked Orchitis Genitourinary System Disorder Organic Brain Syndrome (OBS) Brain Disorder (other than seizures) or Brain Damage Orthostatic Proteinuria Include in Note Section, no Diagnosis checked Osgood-Schlatter Syndrome / Disease Musculoskeletal Disorder Osteitis Include in Note Section, no Diagnosis checked Osteoarthritis Arthritis Osteochrondromas Musculoskeletal Disorder Osteogenesis Imperfecta (OI) Musculoskeletal Disorder Osteoid Osteoma Musculoskeletal Disorder Osteomyelitis Infection – Current or Recurrent Infection Osteopenia Musculoskeletal Disorder Osteoporosis Musculoskeletal Disorder Osteosarcoma Cancer Osteosclerosis Musculoskeletal Disorder Otitis Media Infection – Current or Recurrent Infection Otopalatodigital Syndrome Musculoskeletal Disorder Pachygyria Brain Disorder (other than seizures) or Brain Damage Pallister-Killian Syndrome Genetic / Chromosomal Disorder Pancraniosynostosis Musculoskeletal Disorder Pancreatitis Digestive System Disorder Panhypopituitarism Endocrine Disorder (not Diabetes) Panic Disorder Anxiety Disorder (must verify diagnosis)

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 21 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Paralysis Paralysis, Other than Spinal Cord Injury Paralyzed Vocal Cord Respiratory Condition (other than Asthma) Post-Traumatic Stress or Acute Stress Disorder (must Paranoia verify diagnosis) Paraphilia Sexual or Gender Identity Disorder Paralysis – Spinal Cord Injury (if true) OR Paraplegia Paralysis, Other than Spinal Cord Injury Paresis Neuromuscular Disorder Paresthesia Neuromuscular Disorder Paroxysmal Autonomic Instability And Dystonia Neuromuscular Disorder (PAID) Paroxysmal Ketogenic Dystonia Seizure Disorder Paroxysmal Kinesigenic Dystonia Neuromuscular Disorder Paroxysmal Nocturnal Hemoglobinuria (PNH) Hemophilia / Other Blood Disorder Genetic / Chromosomal Disorder AND Partial 2p Trisomy Syndrome Musculoskeletal Disorder Partial Deletion Chromosome 21 Genetic / Chromosomal Disorder Partial Growth Of Corpus Collosum Brain Disorder (other than seizures) or Brain Damage Partial Monosomy 7p Genetic / Chromosomal Disorder Partial Trisomy 9q Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND Cognitive Pateau Syndrome (Trisomy D / 13) Disability Patent Ductus Arteriosus (PDA) Cardiac Condition Pathological Bone Fracture Musculoskeletal Disorder PDD Pervasive Developmental Disorder (must verify diagnosis) Pectus Carinatum Musculoskeletal Disorder Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections Immune Deficiency (PANDAS) Pelizaeus Merzbacher Syndrome Neuromuscular Disorder Pelvic Floor Dysfunction Digestive System Disorder Pena Shokeir Syndrome Genetic / Chromosomal Disorder Peptic Ulcer Disease (PUD) Digestive System Disorder Pericardial Effusion Cardiac Condition Pericarditis Cardiac Condition Perinatal / Postnatal Depression Depression (must verify diagnosis) Periodic Limb Movement Disorder (PLMD) Neuromuscular Disorder Periventricular Heterotopia Genetic / Chromosomal Disorder Periventricular Leukomalacia (PVL) Brain Disorder (other than seizures) or Brain Damage Blind or Severely Visually Impaired (if child is blind) OR Persistent Fetal Vasculature Syndrome (PFVS) Include in Note Section, no Diagnosis checked Personality Change Due To General Medical Personality Disorder Condition Combined Type Perthes Disease/Disorder Musculoskeletal Disorder Developmental Delay (if present) AND Peters Plus Syndrome Musculoskeletal Disorder Brain Disorder (other than seizures) or Brain Damage AND PHACE Syndrome Cardiac Condition Pheiffer Syndrome Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND Phelan-Mcdermid Syndrome Developmental Delay

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 22 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Phelan-McDermid Syndrome (22q13 Deletion Genetic / Chromosomal Disorder AND Syndrome) Developmental Delay Phenylketonuria (PKU) Metabolic Disorder Pheochromocytoma Endocrine Disorder (not Diabetes) Phlebitis Include in Note Section, no Diagnosis checked Anxiety Disorder (if severe) OR Phobia Include in Note Section, no Diagnosis checked Phonological Disorder Neuromuscular Disorder Pi Type MZ Include in Note Section, no Diagnosis checked Pierre-Robin Syndrome Digestive System Disorder Brain Disorder (other than seizures) or Brain Damage (if Pineal Brain Mass present) OR Include in Note Section, no Diagnosis checked Pituitary Insufficiency Endocrine Disorder (not Diabetes) Plagiocephaly Include in Note Section, no Diagnosis checked Plantar Fasciitis Include in Note Section, no Diagnosis checked Platelet Dysfunction Hemophilia / Other Blood Disorder Pleural Effusion Respiratory Condition (other than Asthma) Pleural Effusion Respiratory Condition (other than Asthma) Plumbism (Lead Poisoning) Include in Note Section, no Diagnosis checked Pneumonia Respiratory Condition (other than Asthma) Pneumonitis Respiratory Condition (other than Asthma) Pneumothorax Respiratory Condition (other than Asthma) Polio Paralysis, Other than Spinal Cord Injury Polycystic Kidney Disease Renal Failure or other Kidney Disease Polycystic Ovarian Syndrome (PCOS) Genitourinary System Disorder Polycythemia Anemia (e.g., Sickle Cell, Fanconi’s) Polydipsia Polydipsia (must verify diagnosis) Polymicrogyria (PMG) Brain Disorder (other than seizures) or Brain Damage Polymyalgia Rheumatica Arthritis Polysplenia Syndrome Cardiac Condition Polysubstance Abuse Substance-Related Disorder (must verify diagnosis) Ponto Cerebellar Hypoplasia Neuromuscular Disorder Poor Muscle Tone Include in Note Section, no Diagnosis checked Failure to Thrive (if present) OR Poor Weight Gain Include in Note Section, no Diagnosis checked Porencephaly Brain Disorder (other than seizures) or Brain Damage Porphyrias Metabolic Disorder Possible Diagnosis of [Anything] Include in Note Section, no Diagnosis checked Posterior Fossa Fluid Cyst / Cerebllum Include in Note Section, no Diagnosis checked Posterior Fossa Syndrome Include in Note Section, no Diagnosis checked Posterior Urethral Valves Genitourinary System Disorder Post-Polio Syndrome Paralysis, Other than Spinal Cord Injury Postural Orthostatic Tachycardia Syndrome (POTS) Neuromuscular Disorder Potocki-Shaffer Syndrome Genetic / Chromosomal Disorder Pragmatic Language Disorder Include in Note Section, no Diagnosis checked Preaxial Polydactyly Musculoskeletal Disorder Precocious Puberty Include in Note Section, no Diagnosis checked Premature Adrenarche Genitourinary System Disorder Prenatal Hydronephrosis Genitourinary System Disorder Pressure Ulcer Wound, Burn, Bedsore, Pressure Ulcer Primary Amenorrhea Genitourinary System Disorder Primary Ciliary Dyskinesia (PCD) Genetic / Chromosomal Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 23 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Primary Lateral Sclerosis Multiple Sclerosis or ALS Primitive Neuroectodermal Tumor Cancer Processing Delays Include in Note Section, no Diagnosis checked Prosopagnosia Brain Disorder (other than seizures) or Brain Damage Prostatic Hypertrophy Genitourinary System Disorder Prostatitis Genitourinary System Disorder Protein Losing Enteropathy Digestive System Disorder Protruding Vertebral Disc Neuromuscular Disorder Prune-Belly Syndrome (Eagle-Barrett) Genitourinary System Disorder Pseudohypoparathyroidism Endocrine Disorder (not Diabetes) Pseudostrabismus Include in Note Section, no Diagnosis checked Psoriasis Skin Disease Psychomotor Retardation Neuromuscular Disorder Schizophrenia and other Psychotic Disorders (must verify Psychosis diagnosis) Ptosis Include in Note Section, no Diagnosis checked Pulmonary Atresia / Stenosis Respiratory Condition (other than Asthma) Pulmonary Hemorrhage Respiratory Condition (other than Asthma) Cardiac Condition AND Pulmonary Hypertension Respiratory Condition (other than Asthma) Pulmonary Hypoplasia Respiratory Condition (other than Asthma) Pulmonary Valve Dysplasia Cardiac Condition Pyloric Stenosis Digestive System Disorder Quadriplegia Paralysis – Spinal Cord Injury Rabies Infection – Current or Recurrent Infection Rasmussen's Encephalitis / Rasmussen Syndrome Brain Disorder (other than seizures) or Brain Damage Raynaud's Disease / Phenomenon / Syndrome Include in Note Section, no Diagnosis checked Reactive Airway Disease Asthma Reactive Attachment Disorder (RAD) Reactive Attachment Disorder (must verify diagnosis) Reading Disorder Include in Note Section, no Diagnosis checked Receptive &/or Expressive Language Disorder / Neuromuscular Disorder Delay Receptive Aphasia Neuromuscular Disorder Rectal Prolapse / Rectal Stenosis Digestive System Disorder Recurring Pneumonia Infection – Current or Recurrent Infection Reduced Oral Motor Skills And Articulation Include in Note Section, no Diagnosis checked Reduction Deformity (hand, arm, leg or foot) Musculoskeletal Disorder Reflux Disease Digestive System Disorder Refsum’s Disease Metabolic Disorder Regulatory Disorder Sensory Disorder (other than Blind or Deaf) Renal Agenesis Renal Failure or other Kidney Disease Renal Calculi Include in Note Section, no Diagnosis checked Renal Insufficiency Renal Failure or other Kidney Disease Respiratory Chain Defect Metabolic Disorder Respiratory Distress Syndrome (RDS) Respiratory Condition (other than Asthma) Restless Leg Syndrome Neuromuscular Disorder Blind or Severely Visually Impaired (if child is blind) OR Retinal Hypoplasia Sensory Disorder (other than Blind or Deaf) Retinoblastoma Cancer Blind or Severely Visually Impaired (if child is blind) OR Retinopathy Sensory Disorder (other than Blind or Deaf)

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 24 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Blind or Severely Visually Impaired (if child is blind) OR Retinopathy of Prematurity (ROP) Include in Note Section, no Diagnosis checked Rhabdomyosacoma Cancer Rheumatic Heart Disease Cardiac Condition Rheumatism Arthritis Rheumatoid Arthritis Arthritis Rhinitis Include in Note Section, no Diagnosis checked Rhizomelic Chondrodysplasia Punctata Musculoskeletal Disorder Nutritional Imbalance (e.g., Malnutrition, Vitamin Ricketts Deficiencies) Developmental Delay AND Cardiac Condition AND Ritscher-Schinzel Syndrome Blind or Severely Visually Impaired (if child is blind) OR Sensory Disorder (other than Blind or Deaf) Robertsonian Translocation (11;22 Unbalance Genetic / Chromosomal Disorder AND Translocation) Developmental Delay Robin Malformation Sequence Digestive System Disorder Robinow Syndrome Genetic / Chromosomal Disorder RSV (Respiratory Syncytial Virus) Infection – Current or Recurrent Infection Genetic / Chromosomal Disorder AND Rubinstein-Taybi Syndrome Cognitive Disability Ruptured Appendix Include in Note Section, no Diagnosis checked Ruptured Disc Neuromuscular Disorder Russell Silver Syndrome Musculoskeletal Disorder Sadism Sexual or Gender Identity Disorder Sanfilippo Syndrome (MPS III) Metabolic Disorder AND Cognitive Disability Scabies Include in Note Section, no Diagnosis checked Schizencephaly Brain Disorder (other than seizures) or Brain Damage Schizoaffective Disorder Schizoaffective Disorder (must verify diagnosis) Schizoid Personality Features / Traits Include in Note Section, no Diagnosis checked Schwachman Diamond Syndrome Genetic / Chromosomal Disorder Sciatica Neuromuscular Disorder Scimitar Syndrome Cardiac Condition Scleroderma Skin Disease Scoliosis Musculoskeletal Disorder Seasonal Adjustment Disorder Depression (must verify diagnosis) Seasonal Affective Disorder Depression (must verify diagnosis) Skin Disease (if severe) OR Seborrheic Eczema Include in Note Section, no Diagnosis checked Seckel Syndrome Musculoskeletal Disorder AND Developmental Delay Segawa Dystonia Neuromuscular Disorder Selective Mutism Include in Note Section, no Diagnosis checked Self Harm Include in Note Section, no Diagnosis checked Self-Injurious Behaviors (SIB) Include in Note Section, no Diagnosis checked Semi-Comatose Brain Disorder (other than seizures) or Brain Damage Sengers Disease Cardiac Condition Senior-Loken Syndrome Renal Failure or other Kidney Disease Sensory Integration Disorder / Dysfunction Sensory Disorder (other than Blind or Deaf) Sensory Issues Sensory Disorder (other than Blind or Deaf) Sensory Neuropathy Sensory Disorder (other than Blind or Deaf) Sensory Processing Disorder Sensory Disorder (other than Blind or Deaf) Separation Anxiety Disorder Anxiety Disorder (must verify diagnosis)

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 25 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Sepsis Infection – Current or Recurrent Infection Septo-Optic Dysplasia Sensory Disorder (other than Blind or Deaf) Severe Anoxic Brain Damage Brain Disorder (other than seizures) or Brain Damage Severe Behavioral Disorder Disruptive Behavior Disorder (must verify diagnosis) Severe Learning Problems In ______Include in Note Section, no Diagnosis checked Sexual Abuse Of A Child Post-Traumatic Stress or Acute Stress Disorder Sexual Disorder, Frotteurism, Paraphilia Sexual or Gender Identity Disorder Sexual Fetish Sexual or Gender Identity Disorder Shaken Baby Syndrome Brain Disorder (other than seizures) or Brain Damage Shingles Infection – Current or Recurrent Infection Shone's Syndrome Cardiac Condition Short Gut Syndrome Digestive System Disorder Short-Term Memory Problems Include in Note Section, no Diagnosis checked Genetic / Chromosomal Disorder AND Shprintzen's Syndrome Immune Deficiency (if present) Shwachman Diamond Syndrome Digestive System Disorder Sickle Cell Disease / Traits Anemia (e.g., Sickle Cell, Fanconi’s) Significant Oral Sensory Deficits Sensory Disorder (other than Blind or Deaf) Digestive System Disorder AND Silent Aspiration Respiratory Condition (other than Asthma) Simpson-Golabi-Behmel syndrome (SGBS) Genetic/Chromosomal Disorder Single Ventricle Defect Cardiac Condition Sinusitis Infection – Current or Recurrent Infection Skeletal Dysplasia Musculoskeletal Disorder Skin Infections Skin Disease Skin Rash Include in Note Section, no Diagnosis checked Sleep Apnea Respiratory Condition (other than Asthma) Sleep Disorder Include in Note Section, no Diagnosis checked Slight Gait Disturbance Include in Note Section, no Diagnosis checked Small Bowel Atresia Digestive System Disorder Small Kidneys Renal Failure or other Kidney Disease Genetic / Chromosomal Disorder AND Smith Magenis Syndrome Cognitive Disability Smith-Lemli-Opitz Syndrome Congenital Abnormality AND Developmental Delay Anxiety Disorder (if severe) OR Social Phobia Include in Note Section, no Diagnosis checked Socialization Disorder / Issues Include in Note Section, no Diagnosis checked Soft Palate Deformity Congenital Abnormality Sotos Syndrome Genetic / Chromosomal Disorder Spasms Neuromuscular Disorder Spastic Diplegia Cerebral Palsy Spastic Dystonia Neuromuscular Disorder Paralysis – Spinal Cord Injury (if true) OR Spastic Quadraplegia Paralysis, Other than Spinal Cord Injury Spastic Quadriparesis Musculoskeletal Disorder Spasticity of Muscles Neuromuscular Disorder Speech and Language Issues Include in Note Section, no Diagnosis checked Speech Apraxia Neuromuscular Disorder Speech Delay / Impairment / Disorder Neuromuscular Disorder Anxiety Disorder (if severe) OR Speech Phobic Select Mutism Include in Note Section, no Diagnosis checked Spinal Cord Arteriovenous Malformation (AVM) Neuromuscular Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 26 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Spinal Muscle Atrophy (Infantile) Spinal Muscular Atrophy Spinal or Lumbar Stenosis Musculoskeletal Disorder Spinal Subluxation Musculoskeletal Disorder Split Hand / Split Foot Anomalies Congenital Abnormality Spondylolistheses Musculoskeletal Disorder Static Encephalopathy Brain Disorder (other than seizures) or Brain Damage Status Epilepticus Seizure Disorder Stevens Johnson Syndrome Skin Disease Stickler Syndrome Genetic / Chromosomal Disorder Stimulant Abuse Substance-Related Disorder (must verify diagnosis) Strabismus (Heterotropia) Include in Note Section, no Diagnosis checked Strep Throat (Streptococcal pharyngitis) Infection – Current or Recurrent Infection Stroke Cerebral Vascular Accident (CVA) (Pre or Postnatal) Sturge-Weber Syndrome Neuromuscular Disorder Stuttering Include in Note Section, no Diagnosis checked Subarachnoid Hemorrhage (SAH) Cerebral Vascular Accident (CVA) (Pre or Postnatal) Subdural Empyema Infection – Current or Recurrent Infection Subglottic Stenosis Respiratory Condition (other than Asthma) Subluxation of [any joint] Musculoskeletal Disorder Submucous Cleft Palate Congenital Abnormality Superior Vena Cava (SVC) Obstruction/Syndrome Cardiac Condition Supernumerary Ring - Chromosome 20 Genetic / Chromosomal Disorder Suprabulbar Palsy Neuromuscular Disorder Cardiac Condition (if severe) OR Supraventricular Tachycardia (PSVT) Include in Note Section, no Diagnosis checked Suspected Autism or PDD Include in Note Section, no Diagnosis checked Sydenham's Chorea Neuromuscular Disorder Symbolic Language Disorder Neuromuscular Disorder Syndactyly Musculoskeletal Disorder Paralysis – Spinal Cord Injury (if true) OR Syringohydromyelia Neuromuscular Disorder Paralysis – Spinal Cord Injury (if true) OR Syringomyelia / Syrnix Neuromuscular Disorder Systemic Lupus Erythematosus (SLE) Immune Deficiency Systemic Mastocytosis Immune Deficiency Tachycardia Cardiac Condition Tay-Sachs Disease Metabolic Disorder AND Cognitive Disability TB / Tuberculosis Respiratory Condition (other than Asthma) T-E Fistula Respiratory Condition (other than Asthma) Temporal Lobe Syndrome Brain Disorder (other than seizures) or Brain Damage Temporomandibular Joint Disorder (TMJ) Include in Note Section, no Diagnosis checked Teschler-Nicola and Killian Syndrome Genetic / Chromosomal Disorder Tethered Spinal Cord Neuromuscular Disorder Tetralogy of Fallot Cardiac Condition THC Abuse Substance-Related Disorder (must verify diagnosis) Thoracic Insufficiency Syndrome Respiratory Condition (other than Asthma) Thoracic Myelomeningocele Musculoskeletal Disorder Thoracogenic Scoliosis Musculoskeletal Disorder Thrombocytopenia Hemophilia / Other Blood Disorder Genetic / Chromosomal Disorder AND Thrombocytopenia Absent Radius Syndrome (TAR) Hemophilia / Other Blood Disorder Thrombocytopenia Purpura Hemophilia / Other Blood Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 27 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Thromboembolus - Cerebral Cerebral Vascular Accident (CVA) (Pre or Postnatal) Thyroid Disorder / Dysfunction Endocrine Disorder (not Diabetes) TIA (Transient Ischemic Attack) Cerebral Vascular Accident (CVA) (Pre or Postnatal) Tic Disorder Neuromuscular Disorder TMJ (Temporomandibular Joint Disorder) Include in Note Section, no Diagnosis checked Toe Walking Spasticity Musculoskeletal Disorder Toriello-Carey Syndrome Brain Disorder (other than seizures) or Brain Damage Torsade De Pointes Cardiac Condition Torsion Dystonia Neuromuscular Disorder Torticollis Musculoskeletal Disorder Total Anomalous Pulmonary Venous Return Cardiac Condition Tourette Syndrome Tourette's Syndrome Toxic Effect of Mercury Include in Note Section, no Diagnosis checked Toxic Effect of Unspecified Lead Compound Include in Note Section, no Diagnosis checked Infection – Current or Recurrent Infection (if congenital) Toxoplasmosis OR Include in Note Section, no Diagnosis checked Tracheal Bronchial Malacia Respiratory Condition (other than Asthma) Tracheitis Infection – Current or Recurrent Infection Tracheoesophageal Fistula (TE Fistula) Respiratory Condition (other than Asthma) Tracheomalacia Respiratory Condition (other than Asthma) Transient Ischemic Attack (TIA) Cerebral Vascular Accident (CVA) (Pre or Postnatal) Transient Tic Disorder Neuromuscular Disorder Transient Tic Disorder Neuromuscular Disorder Transposition of Great Vessels Cardiac Condition Transsphenoidal Encephalocele Congenital Abnormality Transverse Myelitis Neuromuscular Disorder Genetic / Chromosomal Disorder AND Treacher Collins Syndrome Musculoskeletal Disorder Genetic / Chromosomal Disorder AND Tricho-Rhino-Phalangeal Syndrome Musculoskeletal Disorder Tricuspid Atresia Cardiac Condition Trifunctional Protein Deficiency (TFP) Metabolic Disorder Trigeminal Neuralgia Neuromuscular Disorder Paralysis – Spinal Cord Injury (if true) OR Triplegic Paralysis, Other than Spinal Cord Injury Genetic / Chromosomal Disorder AND Trisomy 14 Mosaic Musculoskeletal Disorder Genetic / Chromosomal Disorder AND Trisomy 18 Syndrome (Edwards Symdrome) Cognitive Disability Trisomy 1q Genetic / Chromosomal Disorder Trisomy 20 Genetic / Chromosomal Disorder Trisomy 21 Down Syndrome – Trisomy 21 Genetic / Chromosomal Disorder AND Trisomy 22 (Emanuel Syndrome) Cognitive Disability Genetic / Chromosomal Disorder AND Trisomy 2q3 Developmental Delay Genetic / Chromosomal Disorder AND Trisomy 3q Developmental Delay Genetic / Chromosomal Disorder AND Trisomy 4p Developmental Delay Genetic / Chromosomal Disorder AND Trisomy 5p Developmental Delay

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 28 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Genetic / Chromosomal Disorder AND Trisomy 5q Musculoskeletal Disorder Trisomy 8 Genetic / Chromosomal Disorder Genetic / Chromosomal Disorder AND Trisomy D (Trisomy 13, Pateau Syndrome) Cognitive Disability Truncus Arteriosus Cardiac Condition Tuberculosis Respiratory Condition (other than Asthma) Tuberous sclerosis Tuberous Sclerosis Tuberous Sclerosis (TS) Genetic / Chromosomal Disorder Turner’s Syndrome Genetic / Chromosomal Disorder Twin to Twin Transfusion Syndrome Include in Note Section, no Diagnosis checked Ulcerative Colitis Digestive System Disorder Ulcers – Duodenal, Intestinal, Gastric, or Peptic Digestive System Disorder Underdeveloped Right Lung Respiratory Condition (other than Asthma) Undersocialized Conduct Disorder, Aggressive Type Conduct Disorder (must verify diagnosis) Undifferentiated Sarcoma Cancer Upper Airway Obstruction Respiratory Condition (other than Asthma) Upper Respiratory Tract Infection (URTI) Infection – Current or Recurrent Infection Urea Cycle Disorder Metabolic Disorder Urethral Stenosis / Atresia Genitourinary System Disorder Urinary Incontinence Include in Note Section, no Diagnosis checked Urinary Tract Infection (UTI) Infection – Current or Recurrent Infection URTI (Upper Respiratory Tract Infection) Infection – Current or Recurrent Infection Genetic / Chromosomal Disorder AND Cognitive Disability (if present) AND Vacterl Syndrome/Association (VATER) Digestive System Disorder (if present) AND Genitourinary System Disorder (if present) Valproic Syndrome Musculoskeletal Disorder Valvular Heart Disease Cardiac Condition Vancomycin Resistant Enterococcus (VRE) Infection – Current or Recurrent Infection Genetic / Chromosomal Disorder AND Cognitive Disability (if present) AND VATER Digestive System Disorder (if present) AND Genitourinary System Disorder (if present) Vein Of Galen Malformation Cardiac Condition Velocardiofacial Syndrome (VCFS) (22q11 Genetic / Chromosomal Disorder deletion) Velopharyngeal Dysfunction / Incompetence / Include in Note Section, no Diagnosis checked Insufficiency Ventilator Dependent Respiratory Condition (other than Asthma) Ventricular Septal Defect (VSD) Cardiac Condition Ventricular Tachycardia Cardiac Condition Brain Disorder (other than seizures) or Brain Damage (if Ventriculomegaly Hydrocephalus is present) OR Include in Note Section, no Diagnosis checked Verbal Tics Neuromuscular Disorder Vertical Talis Multiple Sclerosis or ALS Vertigo Include in Note Section, no Diagnosis checked Vesicoureteral Reflux Genitourinary System Disorder Viral Enchephalitis Infection – Current or Recurrent Infection Visceral Hyperalgesia Digestive System Disorder

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 29 of 30 If You See This Diagnosis Check This on CLTS FS Diagnosis Table Blind or Severely Visually Impaired (if child is blind) OR Vision Impairment Sensory Disorder (other than Blind or Deaf) Visual Perception Disorder Sensory Disorder (other than Blind or Deaf) Nutritional Imbalance (e.g., Malnutrition, Vitamin Vitamin [Any] Deficiency Deficiencies) Vitiligo Skin Disease Respiratory Condition (other than Asthma) (if severe) OR Vocal Cord Paralysis Include in Note Section, no Diagnosis checked Voice and Resonance Disorder Include in Note Section, no Diagnosis checked Von Willebrand Disease Hemophilia / Other Blood Disorder VRE (Vancomycin Resistant Enterococcus) Infection – Current or Recurrent Infection VRSA (Vancomycin Resistant Staphylococcus Infection – Current or Recurrent Infection Aureus) VSD (Ventricular Septal Defect) Cardiac Condition Genetic / Chromosomal Disorder AND Waardenburg Syndrome Deaf or Severely Hearing Impaired Renal Failure or other Kidney Disease (if present) AND WARG Syndrome Genitourinary System Disorder (if present) AND Cognitive Disability (if present) Warts Include in Note Section, no Diagnosis checked West Syndrome Seizure Disorder White Matter Disease Neuromuscular Disorder Williams Syndrome Genetic / Chromosomal Disorder Wilms Tumor Cancer Cognitive Disability AND Wolf –Hirschhorn Syndrome (4p deletion) Genetic / Chromosomal Disorder Wolff Parkinson White Syndrome (WPW) Cardiac Condition Worster-Drought Syndrome Cerebral Palsy Wound, Burn, Bedsore, Pressure Ulcer AND Wound Infection Infection-Current or Recurrent Infection XXX Syndrome (Triple X Syndrome) Genetic / Chromosomal Disorder XYY Syndrome (Klinefelter) Genetic / Chromosomal Disorder Yeast Infection Infection – Current or Recurrent Infection

P-00920 (08/2017) CLTS FS P00920 08 17.doc, Page 30 of 30