Office of the Registrar
MSB B640
New Jersey Medical School
Rutgers, The State University of New Jersey
185 South Orange Avenue
Newark, NJ 07103
njms.rutgers.edu/education/registrar
p. 973-972-4640
f. 973-972-6930
Medical Condition Documentation Form
Individuals qualified to complete this form are those who have been trained in the assessment and treatment of
medical conditions. Recommended practitioners include: physicians; physicians assistants; or other relevant medical
personnel qualified to diagnose and treat this medical condition. The diagnostician must be an impartial individual
who is not a family member of the student.
In order to determine eligibility and to provide services, we require documentation of the student's condition. Please
complete only one Physical Health Verification Form for each condition that the student is requesting
accommodations. If the student has multiple conditions, we will require a separate form for each condition.
Documentation assists the New Jersey Medical School and the Rutgers Office of Disability Services staff to:

establish a student's eligibility for services

understand the impact of a student’s condition(s) in an academic environment

and determine strategies and reasonable accommodations to facilitate equal access.
Further information on the components of professionally prepared documentation such as: qualified professionals;
diagnostic statements; diagnostic methodology; current functioning and current documentation; functional
impairment; duration, progression, and stability of a condition; and documentation to support requested reasonable
accommodations can be found at the following link:
https://ods.rutgers.edu/students/documentation-guidelines
In addition to the requested information, please attach any other information you think would be relevant to the
student's academic adjustment.
This form and supporting documentation should be returned directly to:
Julie Ferguson, Asst. Dean for Student Affairs
Rutgers New Jersey Medical School
185 S. Orange Ave., MSB B640
Newark, NJ 07103
Alternatively, they may be faxed to: (973) 972-6930.
Please contact us if you have questions or concerns. Thank you for your assistance.
Physical Health Verification Form
Student's First Name: ___________________________ Student's Last Name: _________________________
Student’s Date of birth: ___________________________Today's Date: ________________________________
I.
Diagnosis
Please list the student’s diagnosis and describe the student’s medical condition:
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
When was the condition first diagnosed:
______________________________________________________
Date of your initial contact with student:
______________________________________________________
Date student was last seen by you: _____________________________________________________________
Frequency of Appointments:
o Once a week
o Twice a week
o Once a month
o Once every six months
o Once a year
o On an as needed basis
What is the severity of the condition?
o
o
o
Mild
Moderate
Severe
Please explain the severity checked above:
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What is the expected duration of the condition? Please select one option:
o 1-3 months
o 3-6 months
o 6-9 months
o 9 months-1 year
o More than 1 year
Is this condition:
o Episodic
o Chronic
Is the student able to ambulate?
o Yes
o No
Can the student negotiate stairs?
o Yes
o No
If no, please explain. _________________________________________________________________________
II.
Current Symptoms
Please list the student's current symptoms, and then indicate what reasonable academic accommodations would be
related to the symptom indicated. More detailed information regarding reasonable academic accommodations can
be found at: https://ods.rutgers.edu/students/reasonable-accommodations
Example:
Symptom: "Due to the student's Crohn’s disorder, the student has frequent stomach pain and is
required to use the restroom numerous times throughout the day Often this is an emergency type
of frequency and may affect attendance."
Recommended Accommodation: “Student will require frequent breaks, including breaks during
quizzes or exams as necessary.”
Symptom 1: _________________________________________________________________________________
Recommended Reasonable Accommodation 1: ______________________________________________________
____________________________________________________________________________________________
Symptom 2: _________________________________________________________________________________
Recommended Reasonable Accommodation 2: ______________________________________________________
____________________________________________________________________________________________
Symptom 3: _________________________________________________________________________________
Recommended Reasonable Accommodation 3: ______________________________________________________
____________________________________________________________________________________________
Symptom 4: _________________________________________________________________________________
Recommended Reasonable Accommodation 4: ______________________________________________________
____________________________________________________________________________________________
III.
Medication and Prognosis
Is the student currently taking medications?
o Yes
o No
If yes, please provide information on each medication below:
Medication 1/Dosage/Frequency: ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date prescribed: _______________________________________________________________________
Side effect(s) that impact the student’s functioning? __________________________________________
_____________________________________________________________________________________
Medication 2/Dosage/Frequency:
________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date prescribed: _______________________________________________________________________
Side effect(s) that impact the student’s functioning? __________________________________________
_____________________________________________________________________________________
Medication 3/Dosage/Frequency:
________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date prescribed: _______________________________________________________________________
Side effect(s) that impact the student’s functioning? __________________________________________
_____________________________________________________________________________________
What is the student's prognosis? _________________________________________________________________
IV.
Summary
Is there anything else you think we should know about the student's medical condition? _____________________
____________________________________________________________________________________________
Role of the person completing this form (check all that apply):
o Treating physician
o Other Treating Professional
o Evaluator
o 2nd Opinion Evaluator
o Other: _______________________________________
Are you related to the student?
o Yes (If yes, please specify your relationship to the student: ____________________________________)
o No
Provider's full name:___________________________________________________________________________
License number: _____________________________________________________________________________
Profession: __________________________________________________________________________________
Provider's address: ____________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Provider's phone/fax: __________________________________________________________________________
Provider's email address : _______________________________________________________________________
To verify that a physician or medical provider filled out this form, we require a copy of a signed letter on your
letterhead. Please attach the letter to this form.