University Of Kansas-College Of Liberal Arts-Sciences Student Academic Services Form (Page 2 of 2) in pdf

Student Name: _____________________________________________________ Student ID Number: _____________________

Semester(s) and year where academics were impacted

Fall 

Spring  Summer 

Year__________

MEDICAL ASSESSMENT FORM: PART II (to be completed by medical/clinical professional)

Date illness/injury began: _________________ Date(s) services were delivered: _____________________________________________________

____________________________________________________________________________________

Nature of illness or injury (diagnosis):

_______________________________________________________________________________________________________

1. What information are you basing your assessment on (multiple office visits, physical therapy, outpatient surgery, etc.)?

_______________________________________________________________________________________________________

2. To what degree did the condition impact the student’s ability to attend class?

 Significant (Please explain how below)  Moderate  Low  Not at all  Undetermined

_______________________________________________________________________________________________________

3. To what degree did the condition impact the student’s ability to study and/or academic performance (impact on attention, memory or

executive functioning)?

 Significant (Please explain how below)  Moderate  Low  Not at all  Undetermined

_______________________________________________________________________________________________________

4. Based on the questions above, how long did the condition impact the student’s ability to attend class and/or their academic performance?

 Chronic 12+ weeks  6+ weeks  3+ weeks  1‐2 weeks  Less than 1 week  Undetermined

5. If condition is chronic, please explain when and how the condition changed such that it impacted the academic semester(s).

_______________________________________________________________________________________________________

6. Is the student currently undergoing treatment/recovery that will impact academic performance in the upcoming semester?

 No  Yes (Please explain impact on upcoming semester and your recommendation for continuing academic coursework)

_______________________________________________________________________________________________________

Additional comments can be attached on a separate statement, if desired.

Medical/Clinical Professional’s Printed Name: _______________________________________________________ License #: ________________

Medical/Clinical Professional’s Signature: ______________________________________________________________ Date: ________________

Medical/Clinical Professional’s email address: ________________________________________________ Phone: __________________________

Address: ________________________________________________ City: _________________________ State: ________ ZIP Code: __________

Thank you for your assistance in filling out this form for one of our students

college.ku.edu/undergrad | clas109@ku.edu | (785) 864-3500 | 1450 Jayhawk Blvd., Room 109 Strong, Lawrence, KS 66045-7535

University Of Kansas-College Of Liberal Arts-Sciences Student Academic Services Form Page 2