M EDICAL E LIGIBILITY F ORM
Make-A-Wish Foundation ® (Singapore) Ltd.
The mission of the Make-A-Wish Foundation
 is to grant the wishes of children living with life-threatening illnesses.
INSTRUCTIONS: This Medical Eligibility Form must be completed and signed by the referred child’s physician and returned to the address below. This Medical Eligibility Form is being signed in connection with a wish request that may be granted by the Make-A-Wish Foundation for:
Patient’s Name & Birth Certificate Number:
Illness:
Patient’s Date of Birth:
Parent(s)/Legal Guardian(s) (“Parent”):
Patient’s Physician (“Physician”) :
PHYSICIAN: PLEASE INDICATE YOUR DETERMINATION BY CHECKING THE APPROPRIATE BOX.
Physician certifies that condition 1 OR 2 listed below has been met.
1.
Physician is familiar with patient’s physical condition and the patient has been diagnosed at the time of referral with an illness on the Medical List.
2.
Physician is familiar with patient’s physical condition and the patient has been diagnosed at the time of referral with a medical condition that is considered life-threatening.
Physician identifies the following medical restrictions and needs that must be considered in fulfilling the wish:
Physician is familiar with patient’s physical condition and certifies that patient is not medically eligible at this time.
Physician’s signature
Date
When completed, please sign and return to:
Programme Services
Make-A-Wish Foundation (Singapore) Ltd.
1 Coleman Street, #04-18 The Adelphi
Singapore 179803
Tel: +65-6334-9474
Fax: +65-6334-4750
Make-A-Wish Foundation  (Singapore) Ltd. 1 2008

M EDICAL E LIGIBILITY F ORM
Make-A-Wish Foundation ® (Singapore) Ltd.
The mission of the Make-A-Wish Foundation
 is to grant the wishes of children living with life-threatening illnesses.
M EDICAL L IST
The purpose of this list is to provide the child’s physician with a list of illnesses that qualify a child for a wish.
Children with illnesses or medical conditions not included on this list may also be qualified by the child’s
physician on a case-by-case basis.
C ARDIOLOGY persistent cyanosis such as:


– All conditions with heart failure or
Dilated Cardiomyopathy with heart failure
Non-correctible & palliated congenital heart defects with either heart failure or cyanosis
 Eisenmenger Syndrome (severe pulmonary
N EUROLOGY – Such as:


Any brain or spinal cord tumour
Any progressive or degenerative neurological
 condition
Any progressive or degenerative myopathy such as muscular dystrophy, Duchenne or other type
 Any severe congenital malformation such as
 hypertension due to congenital heart defect)
Transplant patients, prior to surgery, complications with surgery, or rejections 
Apert’s Syndrome
Severe epilepsy where poorly controlled and/or recurrent attacks of status epilepticus
G ASTROINTESTINAL – Such as:
 Congential Biliary Atresia
 Severe Short Bowel Syndrome
 End Stage Liver Failure
 Transplant patients, e.g. Liver, intestine,
H pancreas; prior to surgery, or complications with surgery, or rejections
EMATOLOGY – Chronic diseases requiring transfusions
O NCOLOGY

– All cancers which severly impact the quality of life such as:
All acute and chronic leukemia’s requiring chemotherapy
 Solid malignant tumors
 Brain tumors
 Children deemed cured after chemotherapy are ineligible unless there is a reoccurrence of the illnesss
R ENAL – Such as: or other chronic therapy such as:
 Aplastic anemia’s
 Thalassemia Major
 Sickle cell disease with complications (cardiac, renal)
I MMUNODEFICIENCY D ISEASE – Such as:
 Congential immune deficiency with known
 limitations on life span or requiring BMT
Acquired immune deficiency syndrome with


P
End-stage Renal failure
Transplant patients, prior to surgery, or complications with surgery, or rejections
ULMONARY – Such as: symptoms (HIV infection with symptoms or significant immune suppression)
M ETABOLIC D ISEASE – Such as:
 Severe Diabetes Mellitus
 Gaucher’s disease, with progressive neurological involvement, and other similar conditions
 Complex severe Cystic Febrosis
 Complex severe Bronchiectasis
 Transplant patients, prior to surgery, or complications with surgery, or rejections
T RAUMA – Such as:


Severe burns – i.e. third dgree burns, affecting more than 30% of total body surface area
Multisystem trauma with permanent disabilities
Make-A-Wish Foundation  (Singapore) Ltd. 2 2008