Name:
ID#:
FACULTY:
(check appropriate categories and strike out inapplicable ones)
Severe -
Completely incapacitated as regards functioning at an academic level (unable to attend any classes).
From:
To:
Moderate -
Able to fulfill some academic obligations, but performance will be considerably affected (unable to attend some classes and some assignments may be late)
Slight -
Able to fulfill academic obligations, but performance will likely be sub-optimal (able to attend classes)
Negligible -
Should not have any significant effect on ability to fulfill academic obligations
The report is based on the patient's description of his/her illness. The patient has completely recovered at this time.
The degree of incapacitation is based on an examination performed on (date). The patient has been seen here on (no.) occasions for this medical condition.
The following symptoms/effects of medication may impair the patient's cognitive abilities:
drowsiness
insomnia
lack of concentration
loss of memory
pain
other
none
Date
Signed
Physician/Nurse
Please print physician's name, address, telephone number and CPSO registration no. Alternatively, affix the physician's stamp to the space provided.
I have read the above information pertaining to my illness. I hereby give permission for release of this information by myself or Health Services to my faculty at the University of Waterloo. If signed by a Health Services' physician, this information may be confirmed by calling Health Services (519) 888-4096.
Student's signature