HSC LEARNING SERVICES MEDICAL DOCUMENTATION FORM Dear Health Care Practitioner, You are being asked by a student who wishes to access learning accommodations at Hillfield Strathallan College to complete the following documentation. The following is to be completed by a treating specialist. All sections of the form must be completed carefully and objectively to ensure an accurate assessment of the student’s disability related to needs. 1. Name of patient/student: __________________________________________ 2. Date of birth of patient/student: ____________________________________ 3. Diagnosis/condition (as per the DSM-5) for learning or physical accommodation: ______________________________________________________________________________________________________________________ 4. Time under your care: ______________________________________________ 5. The anticipated duration of this condition is _________________ to __________________ 6. Please indicate the impact of current symptoms on the following major life activities which may affect the student’s education and academic functioning:
LIFE ACTIVITY Attention and Concentration Memory
(short and long term)
Organization Stress Management Rational thinking and reasoning Social Interactions
(i.e., in-class participation)
Managing Internal Distractions Timely completion of tasks and attendance Cognitive processing of information Limited functioning at certain times of day (please specify): Other (please specify):
No Impact
Mild Impact
(No function limitation)
(Mild or slight)
Moderate Impact (Moderate)
Severe Impact
Unknown
(Functional limitations evident)
(Unable to assess/ unknown)