Physical/Medical Documentation Form
STUDENT NAME: ___________________________________________ STUDENT PHONE: ____________________
STUDENT MAILING ADDRESS:_____________________________________________________________________
STUDENT: Please have this form completed by a qualified professional and return it to the Disability and Learning
Resource Center (address on following page).
To ensure the provision of reasonable and appropriate services for students with physical disabilities at The School of
the Art Institute of Chicago, a licensed professional (e.g. physician, psychologist) must provide current and
comprehensive documentation of the differential diagnosis of the student’s disability. The current ADA defines a
disability as a physical or mental impairment that substantially limits one or more major life activities, such as: manual
tasks, walking, seeing, hearing, speaking, breathing, learning, thinking, concentrating, or working.
Please complete the following form for ________________________________ who has requested disability-related
services and accommodations from our office. (Please print clearly or type.)
1. Diagnosis: __________________________________________________________________________
2. Date of Diagnosis: ____________________________________________________________________
3. Date of your last contact with the student: ________________________________________________
4. What procedures were used to diagnose the disorder?
5. Please describe the current symptoms of this disorder.
6. What is the expected duration, stability, and/or progression of this disorder?
7. Please briefly describe the current treatment, including medications including any possible side effects of the