Questionnaire
Briefly describe your disability and how it affects you in an educational setting:
Date diagnosed:
Include a list of all testing and assessment instruments used in diagnosis evaluation report. NOTE: Test instruments may not apply to physical or sensory disabilities of a permanent or unchanging nature.
Describe present symptoms that fit the criteria for this diagnosis:
Describe the symptoms related to the student’s condition that cause significant impairment to academic performance and major life activity:
List the student’s current medications(s), dosage, frequency, and adverse side effects: