STUDENT MEDICAL FORM

Participant's Name

Formal Diagnosis

Doctor's Name

Allergies

Medications

Seizures (severity/frequency)

Hearing or Vision Impairments

Feeding Needs (ie: feeding tube)

Toileting (toilet trained/assist level in washroom)

Mobility - Ambulatory, Mobility Aids/Adaptive Equipment Used

Speech - Verbal or Non-verbal, Sign Language (level of skill)

Ability to Understand and Follow Instructions

Behavioral Concerns (ie: may bolt from room, aggressive, shy, anxious, separation anxiety)

Sensory Needs (ie: high or low arousal levels, hyper/hypo sensitivities to touch/sound, oral defensiveness)

Behavioral/Sensory Strategies in Place (ie: chew toy, visual supports,choices, reinforcers)

Other Relevant Information

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