# Physical or Medical Conditions Form

The student, whose name and signature appear below, has requested disability related services based on the diagnosis of physical or medical condition. The student is requesting that the following information be provided by a licensed professional trained in the area of medical or physical condition.

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| Type | PDF |
| Size | 272 KB |

[Open original PDF →](https://www.delta.edu/services-support/_documents/physical-or-medical-conditions.pdf)

## Document text

## Physical or Medical Conditions Form

The student, whose name and signature appear below, has requested disability related services based on the diagnosis of physical or medical condition. The student is requesting that the following information be provided by a licensed professional trained in the area of medical or physical condition. Please complete and return this form, and/or send copies of diagnostic evaluations and progress reports (containing the requested information), to the name and address listed above. Please consider this signed consent as authorization to release this information to the Office of Disability Resources at Delta College.

Student Name:

Birthdate:

Student Signature:

Student ID:

## To Be Completed by Professional:

Please note: Information provided is considered in determining appropriate disability related academic accommodations and resources.

Condition/ Diagnosis:

Date of Diagnosis:

Date of last contact with student:

Date of initial contact:

Describe the Functional Limitations (Physical abilities/limitations of condition):

List of Medication(s) / Assistance (dosage, side effects, treatment plan):

Suggested Accommodations or Services:

## Professional Credentials

Signature of Certifying Professional:

Print Name/Title:

License/Certification Number & State of Licensure:

Date:

Address:

Phone:

E-mail: disabilityresources@delta.edu

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<small>Source: [https://www.delta.edu/services-support/_documents/physical-or-medical-conditions.pdf](https://www.delta.edu/services-support/_documents/physical-or-medical-conditions.pdf)</small>