Health Care Form - Providence College (Page 4 of 4) in pdf

Health Care Form - Providence College Page 4

3. List this student’s past and current treatment for his/her disability and current

prescribed medications:

a. Are there significant limitations to the student’s functioning directly related to

the prescribed medications?

Yes: ___________

No: _____________

b. If yes, please describe:

4. Does the student have a disability as a result of this condition?

Yes: __________

No: __________

5. If yes, please state specific recommendations regarding housing accommodations for

this student, and a rationale as to why these housing accommodations are warranted

based upon the student’s functional limitations. Indicate why the housing

accommodations you recommend are necessary (e.g., if you suggest a private

bathroom state the reasons for this request related to the student’s disability).

6. If current treatments (e.g. medications) are successful, why are the above housing

accommodations necessary?

The provider may also send a report that provides additional related information.

The provider completing this form cannot be a relative of the student.

Signature of Provider: _____________________________ ____ Date: ____________

License #: _____________________________

State: _______________________

(Please Print):

Name/title:_______________________________________________________

Address: ________________________________________________________

Phone: __________________________________________________________

Health Care Form - Providence College Page 4