CIHS MEDICAL SUPPLEMENT
If petition is medical in nature.
INSTRUCTIONS FOR PHYSICIAN: This form is to be used to help the student with documentation for an exception to the University of Minnesota’s
policy. When completing this form, you will be asked to rate conditions on a scale of mild, moderate, or severe. Please use these ratings to indicate the
usual state of severity of the conditions during the illness period. Mild is intended to indicate impairment in functioning greater than would be expected for
a college/university student, leading to some impairment in studying and /or missing of classes. Moderate indicates further impairment in functioning that
is not excessive or extreme. Severe indicates extreme difficulty in functioning and complete inability to attend class or study. If additional space is needed,
attach a separate letter on letterhead providing further information.
student name: last first middle student ID
To be completed by physician/medical professional
1. Patient was seen for medical condition on (list all dates):
2. State your diagnosis:
3. Length of treatment:
4. Was the student physically/emotionally incapable of attending classes during the term of the illness?
[ ] Yes [ ] No
5. Rate the severity of how the illness impacted the student’s daily functioning during the term of the illness:
[ ] Mild (less than 2 weeks) [ ] Moderate (2-6 weeks) [ ] Severe (more than 6 weeks)
6. List specific symptoms and how they prevented the student from attending class(es):
7. Extent of the illness or injury as it relates to the student’s ability to participate in class:
Hospitalization (including day hospitalization) required (from ____________________ to _______________________
Confined to bed (from __________________________ to ______________________________)
8. If this condition is a continuation of a prior condition, did the student suffer a relapse, have complications, or require a change in medication
that affected her/his ability to attend classes: If yes, explain and give the date this was diagnosed:
9. Rate how the student’s illness affected the following daily functions:
Ability to concentrate: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Ability to sleep: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Ability to attend class or study: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Energy level: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
Other _________________________________: [ ] Mild [ ] Moderate [ ] Severe [ ] Not applicable
10. Did you recommend ongoing treatment/therapy?
[ ] Yes [ ] No
If yes, how often is/was the required treatment:
[ ] Daily [ ] Weekly [ ] Monthly [ ] Other ___________________
11. On what date do you believe the student can/could have resumed normal daily activities, including attending class(es)?:
12. Other comments pertinent to the student’s circumstances:
By signing this form, you are certifying that the information you provided is true to the best of your knowledge.
Physician’s Name/title Date
Physician’s Signature Phone number
Name and Address of Agency or Medical Provider (e.g., Altru Health, Crookston, MN)
Signature of student authorizing release of medical information.
Student signature Date: