HEALTH EVALUATION FORM

S:\SocServ\Front\Withdrawal- Medical\Withd rawal For ms\HEALTH EVAL FORM (Clearance) Revised 4-20-16.doc7/25/2017

For

Medical Clearance When Applying for Readmission

University of California, Berkeley

(To be completed by medical provider)

Upon completion, please mail or fax this form and a copy of your Release of Information directly to our office at:

University Health Services, Social Services Unit, 2222 Bancroft Way, room 2280, Berkeley, CA 94720, phone 510-642-6074, fax 510-643-0211.

This is a confidential fax machine. If this form is given to the student for hand delivery, please place in a sealed letterhead envelope

with, and sign the outside seal.

The student named below is applying to return to UC Berkeley following a medical leave. The information you provide will be used in helping

reach a determination as to readiness. It will not become a part of the student’s academic or health record, but will be retained in a separate

administrative file.

TO BE COMPLETED BY STUDENT

Student Name (Last, First, MI):

Date:

Student ID#:

DOB:

THE FOLLOWING INFORMATION SHOULD TO BE COMPLETED BY TREATING PROVIDER ONLY

Diagnosis:

Date of Diagnosis:

UC Berkeley is a highly competitive academic institution. Many students find it highly stressful to succeed with the

demanding course loads and expectations. In your professional opinion, do you believe the student is ready to return to UC

Berkeley at this time? Yes No Unable to assess

If yes, please choose from the following:

I believe the student is able to carry a full course load without accommodations.

I believe the student is able to carry a full course load with accommodations.

Please comment:___________________________________________________________________________________________

_________________________________________________________________________________________________________

Please consider a reduced course load for the following reasons:___________________________________________________

__________________________________________________________________________________________________________

Check below degree student’s current condition might impede academic performance:

No Impairment Mild Impairment Moderate Impairment Significant Impairment Severe Impairment

Concentrating

Reading

Writing

Ability to attend class

Ability to multi-task

Ability to complete complex tasks

Ability to follow through

Ability to work collaboratively w/peers

Ability to self-motivate

Other___________________________

Risk Assessment (Check those which currently apply):

Risk of medical instability Not at all Mild Moderate Severe Unable to assess

Risk of suicide: Not at all Mild Moderate Severe Unable to assess

Risk of violence: Not at all Mild Moderate Severe Unable to assess

Self-injurious behavior: Not at all Mild Moderate Severe Unable to assess

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For

Medical Clearance When Applying for Readmission

University of California, Berkeley

(To be completed by medical provider)

Upon completion, please mail or fax this form and a copy of your Release of Information directly to our office at:

University Health Services, Social Services Unit, 2222 Bancroft Way, room 2280, Berkeley, CA 94720, phone 510-642-6074, fax 510-643-0211.

This is a confidential fax machine. If this form is given to the student for hand delivery, please place in a sealed letterhead envelope

with, and sign the outside seal.

The student named below is applying to return to UC Berkeley following a medical leave. The information you provide will be used in helping

reach a determination as to readiness. It will not become a part of the student’s academic or health record, but will be retained in a separate

administrative file.

TO BE COMPLETED BY STUDENT

Student Name ( Last, First, MI ): Date:

Student ID#: DOB:

THE FOLLOWING INFORMATION SHOULD TO BE COMPLETED BY TREATING PROVIDER ONLY

Diagnosis: Date of Diagnosis:

UC Berkeley is a highly competitive academic institution. Many students find it highly stressful to succeed with the

demanding course loads and expectations. In your professional opinion, do you believe the student is ready to return to UC

Berkeley at this time? Yes No Unable to assess

If yes, please choose from the following:

I believe the student is able to carry a full course load without accommodations.

I believe the student is able to carry a full course load with accommodations.

Please comment:___________________________________________________________________________________________

_________________________________________________________________________________________________________

Please consider a reduced course load for the following reasons:___________________________________________________

__________________________________________________________________________________________________________

Check below degree student’s current condition might impede academic performance: No Impairment Mild Impairment Moderate Impairment Significant Impairment Severe Impairment Concentrating Reading Writing Ability to attend class Ability to multi-task Ability to complete complex tasks Ability to follow through Ability to work collaboratively w/peers Ability to self-motivate Other___________________________

Risk Assessment (Check those which currently apply):

Risk of medical instability Not at all Mild Moderate Severe Unable to assess Risk of suicide: Not at all Mild Moderate Severe Unable to assess Risk of violence: Not at all Mild Moderate Severe Unable to assess Self-injurious behavior: Not at all Mild Moderate Severe Unable to assess

Treatment History (Check all that apply): Psychiatric Substance abuse Medical Evaluation only

Outpatient treatment within: 6 months 1year 2-5 years

Partial Hospitalization or Day Care within: 6 months 1 year 2-5 years Residential Treatment within: 6 months 1 year 2-5 years Inpatient Treatment (overnight admission) within: 6 months 1 year 2-5 years

Surgery for present illness within: 6 months 1 year 2-5 years For hospitalization stay, please include discharge summary with this form

Comment:

Treatment Modalities: (Check all that apply): Individual Psychotherapy Group therapy Medication Pain management Bed rest Physical Therapy Nutritional Therapy Other forms of treatment or community services being utilized: Yes No If yes, please specify:___________________________________________________________________________________________________

Treatment Progress: Beginning date:__________________ How often seen:_________________________

of appointments to date: # of appointments to complete treatment:_____

Is patient actively participating in treatment on a regular basis? Yes No

Current condition: Unstable Partially stable Stable (# of weeks _________) Date of last appt:______________ Daily activities impaired: Not at all Mildly Moderately Severely Comment:

Substance Use/Abuse : Active N/A

In Remission (How long) 0-6 months 6-12 months more than 12 months

Medications/Labs: Labs : N/A Normal Abnormal (please describe):_______________________________________________________________

What is the current status of all symptoms which led to withdrawal?

Please be specific:________________________________________________________________________________________________

________________________________________________________________________________________________________

Is student currently taking medications for above symptoms? Yes No Student declines If yes, is student compliant with medication? Yes No Please describe medication (s), date (s) prescribed, and side effects. _____________________________________________________________

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