Download PHYSICAL, SENSORY, and/or HEALTH-RELATED DOCUMENTATION Student/Patient Name

University Of Wisconsin - Stevens Point
Academic Affairs: Division of Academic Success
Disability & Assistive Technology Center
Disability Services
Stevens Point, WI. 54481-3897
(715) 346-3365; FAX: 715-346-4143
PHYSICAL, SENSORY, and/or HEALTH-RELATED DOCUMENTATION
(To be completed by a qualified medical doctor or specialist)
Student/Patient Name: _________________________________________________
(Please type or print neatly / use a separate paper if needed)
1. What is the diagnosis? ____________________________________________________________
2. Level of severity (if applicable): _____Mild _____Moderate _____Severe
3. When was the diagnosis made? ______________________
4. When was your last contact with the above named student? __________________
5. Is this condition:
_______ Temporary
_______ Permanent
6. If sensory, please provide specific explanation of disability (such as visual acuity if low vision/blind; hearing
levels if hearing impaired/deaf) ______________________________________________________
_________________________________________________________________________________
7. If medical or health, provide a description of your patient’s medical condition or symptoms
_________________________________________________________________________________
_________________________________________________________________________________
8. If student is taking medications related to this condition, please list medications:
_________________________________________________________________________________
9. Provide a description of the student’s functional limitations as a result of this condition, and how they
might impact on this student’s academic activities (such as reading, writing, note-taking, concentration,
studying, interactions with others… instructors and students, etc.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Professional’s Signature: _______________________________________ License #: _________________
(If applicable)
Print or type name and title:
____________________________________________________________
____________________________________________________________
Clinic or Medical Facility: _________________________________________________________________
Address: ________________________________________________________________________________
Phone: ___________________ Date: _________________________________
Please address questions regarding documentation, and send this documentation to:
Jim Joque, Director
Phone: 715-346-3365
Roxanne Schuster, Advisor
Fax:
715 346-4143
UWSP Disability & Assistive Technology Center
Email: [email protected]
1900 Reserve Street / 609 LRC
Email: [email protected]
Stevens Point, WI 54481