Form Ssa-5665-Bk - Teacher Questionnaire Page 9
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10VI. MEDICAL CONDITIONS AND MEDICATIONS/HEALTH AND PHYSICAL WELL-BEING
Describe below any chronic or episodic condition (e.g., asthma, sickle cell anemia, depression, seizures).
1
Does the condition have any physical effects (e.g., shortness of breath, reduced stamina, psychomotor
retardation, incontinence, pain) that interfere with the child's functioning at school? How often does the
child experience these physical effects related to the condition?
2
Please check any of the following that the child uses:
Assistive
Glasses
Nebulizer/Inhaler
Technology device
Hearing Aid
Auditory Trainer
Orthopedic devices
Prosthesis
Other (please specify)
3
Is medication prescribed for this child?
Specify below, if known.
No
Yes
Don't know
4
Does this child take the medication on a regular basis?
No
Yes
Don't know
Does this child's functioning change after taking medication?
5
No
Yes
Don't know
If yes, please explain below.
6
No
Yes
Does this child frequently miss school due to illness?
If yes, please explain below.
What else can you tell us about the physical effects of the child's physical or mental condition or
treatment for the condition? (Continue on the last page if needed.)
PLEASE PROVIDE YOUR NAME AND TITLE ON NEXT PAGE. Add any remarks as needed.
Form SSA-5665-BK (09-2011) ef (09-2011)
Page 7
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