Documentation Form For Medical Conditions (Page 3 of 3) in pdf

Documentation Form For Medical Conditions Page 3

Student Name _________________________________________ DOB ___________________________

specific and current functional limitations

7. Describe the student’s

that result

from the impairment’s impact on the activities listed in Question 6, particularly with regard to an

academic environment. If the level of limitation is severe, please discuss in greater detail. If they

have a condition that flares, how often and for what duration do these flares occur?

__________________________________________________________________________________

8. Indicate the dates that the student has been or will be incapacitated.

9. Describe any medications and/or treatments currently being used by the student including type,

dosing, effectiveness, and side effects. How recently has the medication been changed?

10. Is the student compliant with his/her treatment plan?

YES

11. Is the student compliant with medication/therapeutic protocols?

YES

12. Is the student compliant with recommended referrals?

YES

13. Explain how the medication modifies the impact that the disability has on the student’s condition.

14. Although accommodations will be determined by the OSD Disability Specialist based upon the

current functional limitations you have outlined, in your professional opinion, are there any

accommodations you would recommend; i.e., ADA transport, shower chair, note-taking, scribes?

__________________________________________________________________________________

15. Please attach any other supporting documentation including; i.e., vision, audiology, cognitive,

psychological.

DocFormMedicalConditions_090913

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Documentation Form For Medical Conditions Page 3