Medical Information Applicant’s Physician: Physician Town: Physician Phone: Please provide the diagnoses received, for example, Asperger’s Syndrome, ASD, PDD-NOS, NLD, ADHD, or other: Does the applicant know his/her diagnostic label? Yes No What diagnostic words or language have you shared with the applicant about him/herself? Is the applicant currently taking any prescription and/or nonprescription medication? Yes No If yes, please list: Does the applicant have any of the following? Allergies Special Diet Chronic Health Conditions (e.g., asthma, diabetes, seizures) If yes, please explain: Has the applicant ever been hospitalized (medical or psychological)? If yes, please describe reason and date(s): Please describe the applicant’s endurance for physical activities (walking/running/hiking/swimming): Community Provider Information What type of professional support is the applicant currently receiving outside of school? Provider Type Provider Name Purpose / How long? Helpful? Treatment Goals How 1 = No 2 = A Little 3 = Somewhat 4 = Very Therapist Psychologist 1 2 3 4 Social Worker Psychiatrist 1 2 3 4 Speech Therapy 1 2 3 4 Occupational Therapy / 1 2 3 4 Sensory Integration (SI) Social Skills Group 1 2 3 4 Applied Behavioral 1 2 3 4 Analysis (ABA) Other 1 2 3 4 1 2 3 4 Education Information
Medical Information Applicant’s Physician: Physician Town: Physician Phone: Please provide the diagnoses received, for example, Asperger’s Syndrome, ASD, PDD-NOS, NLD, ADHD, or other: Does the applicant know his/her diagnostic label? Yes No What diagnostic words or language have you shared with the applicant about him/herself? Is the applicant currently taking any prescription and/or nonprescription medication? Yes No If yes, please list: Does the applicant have any of the following? Allergies Special Diet Chronic Health Conditions (e.g., asthma, diabetes, seizures) If yes, please explain: Has the applicant ever been hospitalized (medical or psychological)? If yes, please describe reason and date(s): Please describe the applicant’s endurance for physical activities (walking/running/hiking/swimming): Community Provider Information What type of professional support is the applicant currently receiving outside of school? Provider Type Provider Name Purpose / Treatment Goals How long? How Helpful? 1 = No 2 = A Little 3 = Somewhat 4 = Very Therapist Psychologist Social Worker 1 2 3 4 Psychiatrist 1 2 3 4 Speech Therapy 1 2 3 4 Occupational Therapy / Sensory Integration (SI) 1 2 3 4 Social Skills Group 1 2 3 4 Applied Behavioral Analysis (ABA) 1 2 3 4 Other 1 2 3 4 1 2 3 4 Education Information
17-and-under-application.docx