3200 Grand Avenue

Des Moines, Iowa 50312-4198

515.271.1400

Clinical Checklist for Temporary Medical Accommodations

Note: This checklist is used to determine appropriate accommodations for a students
temporary condition and may be completed by a representative of the physician. It must
be accompanied by a signed and dated physicians confirmation on their official letterhead
which should include the doctors name, specialty, address, and phone number.
Type of Injury/Condition
Arm/Hand
Leg/Foot
Head
Other:___________
Full description/details of condition: _______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Date of onset: __________________ Anticipated date of recovery: _____________________
Date of next professional follow-up visit: __________________________
If physical, level of mobility/range of motion: _______________________________________
Can perform timed tasks:
Yes
No
Limited:________
Medications taken for injury/impairment/condition
Name
Rx or OTC
Dose
Frequency

Start Date

Reason for taking

Relevant side effects: ____________________________________________________________

Functional limitations
Please indicate the level of impact in the following areas. If no impact, leave blank.
Area
Mild Moderate Substantial
Area
Mild Moderate Substantial

Breathing
Eating

Seeing
Reading

Hearing
Talking

Walking
Writing

Standing
Sitting

Working
Sleeping

Manual tasks
Lifting/carrying

Memory
Concentrating

Managing
Interacting with
distractions
others

Regular class
On time
attendance
assignments

Quantitative
Processing
Reasoning
Speed
Current symptoms
Symptom

Frequency

Duration

(OVER)

Intensity

 Arm/Hand
Dexterity:
All
None
Limited: _______
Affected Arm/Hand:
Left
Right
Both
Mobility Device Required:
Cast
Splint
Sling
Restrictions on any of the above: _________________________________________
Can type or write:
Yes
No
Limited:________
Can perform physical exams: Yes
No
Limited:________
Can properly manipulate
Yes
No
Limited:________
medical equipment:
Leg/Foot
Ambulatory:
Yes
No
Limited:________
Which leg/foot:
Left
Right
Both
Mobility device required:
Wheelchair: Circle: Manual or Electric
Scooter
Walker
Crutches: Circle: 1 or 2
Cane
Walking Boot
Other:________
Restrictions on any of the above: ____________________________________________
Ability to stand/ambulate
Length of time:
Normal
Limited: _________
Weight bearing:
Yes
Limited: _________ No weight bearing
No
Assistance required: Yes
Ability to sit
Length of time:
Extremity elevated:

Normal
Anytime sitting

Limited: _________
Intermittent

N/A

Traumatic/Acquired Brain Injury/Concussion

Due to the nature of head injuries, please explain: _____________________________________
______________________________________________________________________________
______________________________________________________________________________
Restrictions/Limitations: _________________________________________________________
______________________________________________________________________________
How is condition impacting students daily life?

Additional information/recommendations: ___________________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Physicians Representative (Print)

Date

Physicians Representative (Sign)

Phone Number