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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