According to that website:
Debilitating Medical Condition: Check appropriate boxes.
[ ] 1. Malignant neoplasm (Cancer)
[ ] 2. Glaucoma
[ ] 3. Positive status for Human Immunodeficiency Virus (HIV) or Acquired Immune
Deficiency Syndrome (AIDS)
[ ] 4. Agitation due to Alzheimers Disease
5.
A medical condition or treatment for a medical condition that produces for a
specific patient one or more of the following: (check all that apply)
[ ] a. Cachexia
[ ] b. Severe pain
[ ] c. Severe nausea
[ ] d. Seizures, including but not limited to seizures caused by epilepsy
[ ] e. Persistent muscle spasms, including but not limited to spasms caused by
multiple sclerosis.