ࡱ>  Root Entry@wg(@MatOST,g(,g(MMMN0   !"#$%&'()*+,-./012345678NDP0   8=/d  o TPHYSICAL/HEALTH IMPAIRED EVALUATION SUMMARY Sevier County Schools/Department of Special Education Student _______________________________________ School__________________ Date of Birth ___________________________ Age ____ Grade _____ I. Social and Physical Adaptive Behaviors A. abSocial and/or physical adaptive behaviors related to the impairment are interfering with the students educational performance. qYes qNo B. abIf yes, document deficit areas: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ II. School History and Level of Educational Performance A. tabSummary of past educational performance: _______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ B. tabCurrent levels of educational performance: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date of Medical Evaluation (report attached): _____________________________ This report completed by: ________________________________ ______________________ _____________ Signature Position Date Revised 12/01 - /16@Dw{yvqnjjnvqnn y-dfh1:yyysbQJQJ8880:{>@y{xxxxg`Oxx``8808 kj__X    88:Times New RomanP ZapfDingbatsTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman Baltic