This form contains 215 fields organized into 25 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Applicant Signature and Date
Applicant Signature	Text	Provide the signature of the applicant or authorized representative.
Signature Date	Date	Provide the date the signature was made.
Consent Options
Give Consent	Radiobutton	Check this box if you consent to Service Canada obtaining your medical and personal information from third parties to assess your eligibility for CPP disability benefits.
Do Not Give Consent	Radiobutton	Check this box if you do not consent to Service Canada obtaining your medical and personal information from third parties.
Expected duration
Less than 1 year	Radiobutton	Check this box if the expected duration of the condition is less than 1 year.
More than 1 year	Radiobutton	Check this box if the expected duration of the condition is more than 1 year.
Expected Duration
Expected Duration: Less than 1 year	Radiobutton	Check this box if the expected duration of the condition is less than 1 year.
Expected Duration: More than 1 year	Radiobutton	Check this box if the expected duration of the condition is more than 1 year.
Expected duration less than 1 year	Radiobutton	Check this box if the expected duration of the condition is less than 1 year.
Expected duration more than 1 year	Radiobutton	Check this box if the expected duration of the condition is more than 1 year.
First Medication Record
First Medication: Medication, Dosage, and Frequency	Text	Enter the name of the medication, its dosage, and the frequency of administration for the first medication record.
First Medication: Actual/Proposed Start Date	Date	Enter the actual or proposed start date for the first medication record.
First Medication: Actual/Estimated End Date	Date	Enter the actual or estimated end date for the first medication record.
First Medication: Response and Remarks	Text	Provide details about the response to the first medication, such as efficacy, side effects, and any other relevant remarks.
First Other Treatment Record
First Other Treatment Type and Frequency	Text	Enter the type and frequency of the first other treatment.
First Other Treatment Start Date	Date	Enter the actual or proposed start date for the first other treatment.
First Other Treatment End Date	Date	Enter the actual or estimated end date for the first other treatment.
First Other Treatment Response and Remarks	Text	Enter the response to the first other treatment, such as efficacy or side effects, and any other relevant remarks.
First Terminal Diagnosis
First Terminal Diagnosis	Text	Provide the patient's first terminal diagnosis.
First Terminal Diagnosis ICD-9-CM Code	Text	Provide the ICD-9-CM code for the patient's first terminal diagnosis.
First Terminal Diagnosis Symptom Onset Date	Date	Provide the date when symptoms for the patient's first terminal diagnosis began.
Frequency
Frequency: Recurrent/Episodic	Radiobutton	Check this box if the medical condition's frequency is recurrent or episodic.
Frequency: Continuous	Radiobutton	Check this box if the medical condition's frequency is continuous.
Frequency: Unknown	Radiobutton	Check this box if the medical condition's frequency is unknown.
Recurrent/Episodic	Radiobutton	Check this box if the medical condition or symptom occurs repeatedly but with periods of remission.
Continuous	Radiobutton	Check this box if the medical condition or symptom is ongoing without interruption.
Unknown	Radiobutton	Check this box if the frequency of the medical condition or symptom is not known.
Recurrent/episodic	Radiobutton	Check this box if the frequency of the medical condition is recurrent or episodic.
Continuous	Radiobutton	Check this box if the frequency of the medical condition is continuous.
Unknown	Radiobutton	Check this box if the frequency of the medical condition is unknown.
Functional limitation(s)
Functional Limitation Description	Text	Provide a detailed description of the functional limitation(s).
General
Social Insurance Number	Text	Please enter your Social Insurance Number. Max length: 9 characters
Preferred language: English	Radiobutton	Check this box if English is your preferred language for communication.
Preferred language: French	Radiobutton	Check this box if French is your preferred language for communication.
Optional Title: Mr.	Radiobutton	Check this box if your title is Mr.
Optional Title: Mrs.	Radiobutton	Check this box if your title is Mrs.
Optional Title: Miss	Radiobutton	Check this box if your title is Miss.
Optional Title: Ms.	Radiobutton	Check this box if your title is Ms.
First Name	Text	Please provide your first name.
Middle Name	Text	Please provide your middle name.
Last Name(s)	Text	Please provide your last name or names.
Date of Birth	Date	Please enter your date of birth.
Last Name at Birth	Text	Please enter your last name at birth if it is different from your current last name.
Mailing Address	Text	Please provide your complete mailing address, including street, city, province/territory, country (if applicable), and postal code.
Telephone Number	Text	Please enter your telephone number.
Alternate Telephone Number	Text	Please enter an alternate telephone number.
Best time to contact: Morning	Radiobutton	Check this box if the morning is the best time for Service Canada to contact you.
Best time to contact: Afternoon	Radiobutton	Check this box if the afternoon is the best time for Service Canada to contact you.
Best time to contact: Please don't call, send letters only	Radiobutton	Check this box if you prefer Service Canada not to call and to send letters only.
Social Insurance Number	Text	Please enter the applicant's social insurance number. Max length: 9 characters
Patient Height	Number	Please enter the patient's height in centimeters.
Patient Weight	Number	Please enter the patient's weight in kilograms.
Medical Condition	Text	Please enter the medical condition that is being reported.
ICD-9-CM Code	Text	Please enter the ICD-9-CM code for the medical condition.
Date of Symptom Onset	Date	Please enter the date when the symptoms first started.
Impairments	Text	Please describe any impairments resulting from the medical condition.
Functional Limitations	Text	Please describe any functional limitations caused by the medical condition.
Condition likely to improve	Radiobutton	Check this box if the medical condition is likely to improve.
Condition likely to deteriorate	Radiobutton	Check this box if the medical condition is likely to deteriorate.
Condition likely to remain the same	Radiobutton	Check this box if the medical condition is likely to remain the same.
Prognosis unknown	Radiobutton	Check this box if the prognosis of the medical condition is unknown.
Expected duration less than 1 year	Radiobutton	Check this box if the expected duration of the condition is less than 1 year.
Expected duration more than 1 year	Radiobutton	Check this box if the expected duration of the condition is more than 1 year.
Frequency recurrent/episodic	Radiobutton	Check this box if the frequency of the condition is recurrent or episodic.
Frequency continuous	Radiobutton	Check this box if the frequency of the condition is continuous.
Frequency unknown	Radiobutton	Check this box if the frequency of the condition is unknown.
Medication 1	Text	Please provide details for the first medication, including its dosage and frequency.
Medication 1 Start Date	Date	Please enter the actual or proposed start date for the first medication.
Medication 1 End Date	Date	Please enter the actual or estimated end date for the first medication.
Medication 1 Response and Remarks	Text	Please describe the response to the first medication, including efficacy, side effects, and any other relevant remarks.
Medication 2 Start Date	Date	Please enter the actual or proposed start date for the second medication.
Medication 2 End Date	Date	Please enter the actual or estimated end date for the second medication.
Medication 2 Response and Remarks	Text	Please describe the response to the second medication, including efficacy, side effects, and any other relevant remarks.
Medication 2	Text	Please provide details for the second medication, including its dosage and frequency.
Medication 3 Start Date	Date	Please enter the actual or proposed start date for the third medication.
Medication 3 End Date	Date	Please enter the actual or estimated end date for the third medication.
Medication 3 Response and Remarks	Text	Please describe the response to the third medication, including efficacy, side effects, and any other relevant remarks.
Medication 3	Text	Please provide details for the third medication, including its dosage and frequency.
Other Treatment 1	Text	Please provide details for the first other treatment, including its type and frequency.
Other Treatment 1 Start Date	Date	Please enter the actual or proposed start date for the first other treatment.
Other Treatment 1 End Date	Date	Please enter the actual or estimated end date for the first other treatment.
Other Treatment 1 Response and Remarks	Text	Please describe the response to the first other treatment, including efficacy, side effects, and any other relevant remarks.
Other Treatment 2	Text	Please provide details for the second other treatment, including its type and frequency.
Other Treatment 2 Start Date	Date	Please enter the actual or proposed start date for the second other treatment.
Other Treatment 2 End Date	Date	Please enter the actual or estimated end date for the second other treatment.
Other Treatment 2 Response and Remarks	Text	Please describe the response to the second other treatment, including efficacy, side effects, and any other relevant remarks.
Other Treatment 3	Text	Please provide details for the third other treatment, including its type and frequency.
Other Treatment 3 Start Date	Date	Please enter the actual or proposed start date for the third other treatment.
Other Treatment 3 End Date	Date	Please enter the actual or estimated end date for the third other treatment.
Other Treatment 3 Response and Remarks	Text	Please describe the response to the third other treatment, including efficacy, side effects, and any other relevant remarks.
Social Insurance Number	Text	Enter your Social Insurance Number. Max length: 9 characters
Medical Condition	Text	Provide the name of the medical condition.
ICD-9-CM Code	Text	Enter the ICD-9-CM code for the medical condition in the format XXX.X.
Date of Symptom Onset	Date	Provide the date when the symptoms of the medical condition first appeared.
Impairment(s) Description	Text	Describe the impairment(s) resulting from the medical condition.
Functional Limitation(s) Description	Text	Describe the functional limitation(s) caused by the medical condition.
Improve	Radiobutton	Check this box if the condition is likely to improve.
Deteriorate	Radiobutton	Check this box if the condition is likely to deteriorate.
Remain the same	Radiobutton	Check this box if the condition is likely to remain the same.
Unknown Prognosis	Radiobutton	Check this box if the prognosis of the condition is unknown.
Less than 1 year	Radiobutton	Check this box if the expected duration of the condition is less than 1 year.
More than 1 year	Radiobutton	Check this box if the expected duration of the condition is more than 1 year.
Recurrent/Episodic	Radiobutton	Check this box if the frequency of the condition is recurrent or episodic.
Continuous	Radiobutton	Check this box if the frequency of the condition is continuous.
Unknown Frequency	Radiobutton	Check this box if the frequency of the condition is unknown.
Medication 1 Details	Text	Provide the medication(s) details, dosage, and frequency for the first entry.
Medication 1 Start Date	Date	Provide the actual or proposed start date for the first medication entry.
Medication 1 End Date	Date	Provide the actual or estimated end date for the first medication entry.
Medication 1 Response and Remarks	Text	Describe the response to the first medication (e.g., efficacy, side effects) and any other remarks.
Medication 2 Details	Text	Provide the medication(s) details, dosage, and frequency for the second entry.
Medication 2 Start Date	Date	Provide the actual or proposed start date for the second medication entry.
Medication 2 End Date	Date	Provide the actual or estimated end date for the second medication entry.
Medication 2 Response and Remarks	Text	Describe the response to the second medication (e.g., efficacy, side effects) and any other remarks.
Medication 3 Details	Text	Provide the medication(s) details, dosage, and frequency for the third entry.
Medication 3 Start Date	Date	Provide the actual or proposed start date for the third medication entry.
Medication 3 End Date	Date	Provide the actual or estimated end date for the third medication entry.
Medication 3 Response and Remarks	Text	Describe the response to the third medication (e.g., efficacy, side effects) and any other remarks.
Other Treatment 1 Details	Text	Provide the type and frequency of the first other treatment.
Other Treatment 1 Start Date	Date	Provide the actual or proposed start date for the first other treatment.
Other Treatment 1 End Date	Date	Provide the actual or estimated end date for the first other treatment.
Other Treatment 1 Response and Remarks	Text	Describe the response to the first other treatment (e.g., efficacy, side effects) and any other remarks.
Other Treatment 2 Details	Text	Provide the type and frequency of the second other treatment.
Other Treatment 2 Start Date	Date	Provide the actual or proposed start date for the second other treatment.
Other Treatment 2 End Date	Date	Provide the actual or estimated end date for the second other treatment.
Other Treatment 2 Response and Remarks	Text	Describe the response to the second other treatment (e.g., efficacy, side effects) and any other remarks.
Other Treatment 3 Details	Text	Provide the type and frequency of the third other treatment.
Other Treatment 3 Start Date	Date	Provide the actual or proposed start date for the third other treatment.
Other Treatment 3 End Date	Date	Provide the actual or estimated end date for the third other treatment.
Other Treatment 3 Response and Remarks	Text	Describe the response to the third other treatment (e.g., efficacy, side effects) and any other remarks.
Social Insurance Number	Text	Enter the patient's Social Insurance Number. Max length: 9 characters
Recommended Patient Stop Working	Radiobutton	Check this box if you recommended that the patient stop working.
No Recommendation to Stop Working	Radiobutton	Check this box if you did not recommend that the patient stop working.
Stop Working Not Discussed	Radiobutton	Check this box if whether the patient should stop working was not discussed.
Stop Working Date	Date	Provide the date the patient was recommended to stop working.
Expect Patient to Return to Work	Radiobutton	Check this box if you expect your patient to return to any type of work in the future.
Do Not Expect Patient to Return to Work	Radiobutton	Check this box if you do not expect your patient to return to any type of work in the future.
Unknown if Patient Will Return to Work	Radiobutton	Check this box if it is unknown whether your patient will return to any type of work in the future.
Return in 6 to 12 Months	Radiobutton	Check this box if you expect the patient to return to work in 6 to 12 months.
Return in 12 to 24 Months	Radiobutton	Check this box if you expect the patient to return to work in 12 to 24 months.
Return in More Than 24 Months	Radiobutton	Check this box if you expect the patient to return to work in more than 24 months.
Return Time Unknown	Radiobutton	Check this box if the expected timeframe for the patient's return to work is unknown.
Usual Work	Radiobutton	Check this box if you expect the patient will be able to do their usual work.
Modified Work	Radiobutton	Check this box if you expect the patient will be able to do modified work.
Another Type of Work Requiring Training	Radiobutton	Check this box if you expect the patient will be able to do another type of work that will require training.
Other Type of Work	Radiobutton	Check this box if the patient will be able to do another type of work not listed.
Other Type of Work	Text	Specify another type of work the patient will be able to do.
Other Relevant Information	Text	Provide any additional information relevant to the applicant's current and future ability to work, including details about planned investigations, specialist consultations, or reasons for an unknown prognosis.
Social Insurance Number	Text	Enter your Social Insurance Number. Max length: 9 characters
Longitudinal clinical notes	Checkbox	Check this box if you are including longitudinal clinical notes as supporting documents.
Medical investigation report(s)	Checkbox	Check this box if you are including medical investigation report(s) as supporting documents.
Specialist's report(s)	Checkbox	Check this box if you are including specialist's report(s) as supporting documents.
Hospital discharge report(s)	Checkbox	Check this box if you are including hospital discharge report(s) as supporting documents.
Other (please specify)	Checkbox	Check this box if you are including other types of reports not listed and specify the type.
Other Report Type	Text	Specify the type of report being included if it is not one of the listed options.
General practice physician or physician certified in family medicine (CCFP)	Radiobutton	Check this box if you are a general practice physician or a physician certified in family medicine (CCFP).
Other physician specialist (please specify)	Radiobutton	Check this box if you are another type of physician specialist and specify your specialty.
Nurse practitioner	Radiobutton	Check this box if you are a nurse practitioner.
Registered nurse in a geographically isolated community (not urban or rural)	Radiobutton	Check this box if you are a registered nurse practicing in a geographically isolated community (not urban or rural).
Other Physician Specialist	Text	Specify the type of other physician specialist.
Declarant Name	Text	Enter your full name as the declarant.
Declarant Address and Telephone Number	Text	Provide your full address and telephone number.
Declarant Signature	Text	Provide your signature.
Declaration Date	Date	Enter the date of the declaration.
Grave Condition Declaration
Grave Condition Yes	Checkbox	Check this box if the patient has a grave condition as defined for the purpose of CPP, which is a condition included in the list of severe and rapidly progressive medical conditions in Annex A, and you will provide details in Section 5.
Impairment(s)
Impairment Description	Text	Provide a detailed description of the impairment(s).
Medical Condition Details
Medical Condition	Text	Provide the name of the medical condition.
ICD-9-CM Code	Text	Enter the ICD-9-CM code for the medical condition.
Date of Symptom Onset	Date	Enter the date when the symptom onset occurred.
Patient Visit and Treatment Details
Number of Visits in Past 12 Months	Text	Enter the total number of times the patient has visited your office within the last 12 months.
Date of Last Office Visit	Date	Provide the date of the patient's most recent office visit.
Start Date of Primary Medical Condition Treatment	Date	Indicate the date when you first began treating the patient's primary medical condition.
Prognosis
Improve	Radiobutton	Check this box if the medical condition is likely to improve.
Deteriorate	Radiobutton	Check this box if the medical condition is likely to deteriorate.
Remain the Same	Radiobutton	Check this box if the medical condition is likely to remain the same.
Unknown	Radiobutton	Check this box if the prognosis for the medical condition is unknown.
Prognosis: Improve	Radiobutton	Check this box if the condition is likely to improve.
Prognosis: Deteriorate	Radiobutton	Check this box if the condition is likely to deteriorate.
Prognosis: Remain the Same	Radiobutton	Check this box if the condition is likely to remain the same.
Prognosis: Unknown	Radiobutton	Check this box if the prognosis for the condition is unknown.
Prognosis Condition Likelihood
Improve	Radiobutton	Check this box if the condition is likely to improve.
Deteriorate	Radiobutton	Check this box if the condition is likely to deteriorate.
Remain the same	Radiobutton	Check this box if the condition is likely to remain the same.
Unknown	Radiobutton	Check this box if the future likelihood of the condition (improve, deteriorate, or remain the same) is unknown.
Second Medication Record
Second Medication Record - Start Date	Date	Provide the actual or proposed start date for the second medication.
Second Medication Record - End Date	Date	Provide the actual or estimated end date for the second medication.
Second Medication Record - Response and Remarks	Text	Describe the patient's response to the second medication, including efficacy, side effects, and any other relevant remarks.
Second Medication Record - Medication, Dosage, and Frequency	Text	Enter the name of the second medication, its dosage, and frequency of administration.
Second Other Treatment Record
Second Other Treatment Type and Frequency	Text	Enter the type and frequency of the second other treatment.
Second Other Treatment Proposed Start Date	Date	Enter the actual or proposed start date of the second other treatment.
Second Other Treatment Estimated End Date	Date	Enter the actual or estimated end date of the second other treatment.
Second Other Treatment Response and Remarks	Text	Provide details about the response to the second other treatment, including efficacy, side effects, and any other remarks.
Social Insurance Number
Social Insurance Number	Text	Enter the Social Insurance Number. Max length: 9 characters
Social Insurance Number	Text	Provide the Social Insurance Number. Max length: 9 characters
Social Insurance Number	Text	Provide your Social Insurance Number. Max length: 9 characters
Social Insurance Number	Text	Provide the Social Insurance Number. Max length: 9 characters
Social Insurance Number	Text	Enter the individual's Social Insurance Number. Max length: 9 characters
Terminal Condition Declaration
Terminal Condition: Yes	Checkbox	Check this box if the patient has a medical condition that is terminal, meaning it cannot be cured or adequately treated and is reasonably expected to result in death within 6 months.
Third Medication Record
Third Medication Start Date	Date	Enter the actual or proposed start date for the third medication.
Third Medication End Date	Date	Enter the actual or estimated end date for the third medication.
Third Medication Response and Remarks	Text	Provide details about the patient's response to the third medication, including efficacy, side effects, and any other relevant remarks.
Third Medication Dosage and Frequency	Text	Enter the name of the third medication, its dosage, and the frequency of administration.
Third Other Treatment Record
Third Other Treatment Type and Frequency	Text	Enter the type and frequency of the third other treatment.
Third Other Treatment Start Date	Date	Provide the actual or proposed start date for the third other treatment.
Third Other Treatment End Date	Date	Provide the actual or estimated end date for the third other treatment.
Third Other Treatment Response and Remarks	Text	Enter the response to the third other treatment, including efficacy, side effects, and any other relevant remarks.
Witness Information
Witness First Name	Text	Enter the first name of the witness.
Witness Middle Name	Text	Enter the middle name of the witness.
Witness Last Name	Text	Enter the last name(s) of the witness.
Witness Telephone Number	Text	Enter the telephone number of the witness.
Witness Signature and Date
Witness Signature	Text	Provide the signature of the witness.
Witness Signature Date	Date	Provide the date the witness signed this form.
Years Patient in Care
1 year or less	Radiobutton	Check this box if the patient has been in your care for 1 year or less.
1 to 2 years	Radiobutton	Check this box if the patient has been in your care for 1 to 2 years.
3 to 4 years	Radiobutton	Check this box if the patient has been in your care for 3 to 4 years.
5 years or more	Radiobutton	Check this box if the patient has been in your care for 5 years or more.

SC ISP-2519, Medical Report for Canada Pension Plan Disability Benefits Instructions