Purpose: The student named below has indicated that s he has asthma or allergies that rise to the le 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the student's name and date at the top of the form. This information is crucial for identifying the individual requiring accommodations.
3. Fill in the diagnosis details, including the date of diagnosis and the last visit for this condition. Accurate dates help establish a timeline for treatment.
4. Indicate the severity of the condition by checking one of the options: Mild, Moderate, Substantial, or In Remission. This helps assess the level of accommodation needed.
5. Answer whether the student has been treated in an emergency room or hospital in the past year and provide details on any hospitalizations related to this condition.
6. List any environmental factors that exacerbate this condition, as well as any prescription medications being taken, including dosage and frequency.
7. Describe any functional limitations caused by this condition and recommend accommodations that are clearly linked to these limitations.
8. Finally, ensure that a medical professional completes their section with their signature, license number, and contact information before submitting.

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