SMC Accessibility Resources Chronic Health Condition Form

TO BE COMPLETED BY MEDICAL PROVIDERS

Student Information-- Name Student Information-- Name * First Middle Last
Student's Email *
SMC ID Number
Student's Cellphone Number Student's Cellphone Number * - ### - ### ####
Medical Provider Information
Medical Provider's Name Medical Provider's Name * Title First Middle Last Suffix
Medical Provider's Degree(s) and Specialties *
Medical Provider's Phone Number Medical Provider's Phone Number * - ### - ### ####
Medical Provider's Address Medical Provider's Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Medical Provider's License Number/State of Licensure(s) *
Chronic Medical Condition Information
Diagnosis *
Approximate Date(s) of Onset *
Date of Your Last Clinical Contact with the Student? Date of Your Last Clinical Contact with the Student? * / MM / DD YYYY
Which methods did you use to arrive at the student's diagnosis; i.e., testing, lab work, x-rays, interview with student, etc.?
Severity of Symptoms WITH Mitigation?

Severity of Symptoms WITH Mitigation? Mild Moderate Severe Other Other
Severity of Symptoms WITHOUT Mitigation? *

Severity of Symptoms WITHOUT Mitigation? Mild Moderate Severe Other Other
Frequency and duration of symptoms of student's condition?

Frequency and duration of symptoms of student's condition? Daily 1-3 times per week 1-3 times per month 1-3 times per year None--symptoms under control with medication/treatment Other Other
What is the student's current treatment? How frequently does the student receive treatment? What medications, if any, are used to treat the student, and what are their side effects?
In what ways does the disability substantially impact the student's functional abilities? Please consider areas such as the classroom, student housing, homework, and assignments.
As the student's medical provider, what accommodations to you recommend for the student to have equal access to the college's programs and services?
Will you continue seeing the student for follow-up appointments?

Will you continue seeing the student for follow-up appointments? YES NO Other Other
If yes, when is the next appointment? If yes, when is the next appointment? / MM / DD YYYY
Is there any other pertinent information that you wish to share to assist SMC in providing accommodations to the student?
Please type your initial below to certify that you are the person who has completed this form. In typing your initials, you are also attesting that you are not related to the student by blood or through marriage. In addition, you attest that all of the information you have provided is accurate and current.
Completion Date of Form Completion Date of Form / MM / DD YYYY

SMC Accessibility Resources Chronic Health Condition Form

SMC Accessibility Resources Chronic Health Condition Form

Medical Provider Information

Chronic Medical Condition Information