CONFIDENTIAL HEALTH FORM

PERSONAL MEDICAL HISTORY

Name of Applicant: __________________________ Applying for: __________________

Date: ___/___/____

 

Comment on all positive answer's in the space below or on a separate sheet.

All medical information is subject to review and approval of Base Doctor.

Please answer all questions before submitting it to your doctor.

1. Have you ever had, or do you now have any of the following?

Explanation of Yes answers: _____________________________________________________

Are you under doctor's care for any condition? Yes []; No[]; (If Yes please specify):

___________________________________________________________________________

Are you taking any medication at this time? Yes []; No[]; (If Yes please specify): ___________________________________________________________________________

Have you had any infections disease(s) in the past twelve months Yes []; No[];

(If Yes please specify): _____________________________________________________

Would you rate your health condition as: Excellent []; Good []; Fair []; Poor [].

Have you been immunized against:

Polio Yes []; No[]; If Yes, When: ________________

Tetanus Yes []; No[]; If Yes, When: ________________

Typhoid Yes []; No[]; If Yes, When: ________________

Yellow Fever Yes []; No[]; If Yes, When: ________________

Do you have any physical problem that would affect your ability to work in any way? Yes []; No[];

(If Yes please specify): _________________________________________________________

 

TO THE BEST OF MY KNOWLEDGE THE INFORMATION STATED IN THIS APPLICATION

IS CORRECT AND ACCURATE.

Students Signature: ______________________________________ Date: ________________

TO THE PHYSICIAN

Applicant's Name ___________________________

The above applicant has applied to be Student [] / Staff [] with Youth With A Mission. This is a missionary service in which there will be some physical exertion in a group situation. This program will require good health and endurance. Please review the PERSONAL HISTORY information on the other page, fill in the portion below and make your additional comments.

 

PLEASE PRINT

Please answer the following questions regarding the applicant's health.

Blood Pressure: ________________ Pulse: _______________ Blood Type: ______________

1. a) Weight: ____st _____Ibs (_____kg)

. . b) Height: _____ft _____ins (_____cm)

2. a) Is the applicant under medical supervision at this time or taking any medication?

. . b) If so, what kind?

3. Would you consider the applicant in good physical health?

4. Is applicant's sight, hearing and speech normal

5. Is applicant's chest, heart and blood pressure normal?

6. Is there any respiratory problems?

7. Has the applicant adequate emotional and mental stability to undertake missionary service?

8. Please list any significant medical and/or psychiatric history

Please add here any additional comments regarding the applicants health or special limitations affecting physical, mental or emotional capabilities and attach any additional comments to this sheet.

PHYSICIAN'S RECOMMENDATION

[] Accept without limitations.

[] Should remain in areas where adequate medical care is available.

[] Acceptable within limitations (specify): _____________________________________

Doctor's Name (please print): ___________________________________________________

Address: ____________________________________________________________________

Doctor's Signature: ________________________________ Date : _____________________

Tel: __________________ Fax: ____________________ Email: _______________________

Please return this medical report to Youth With A Mission, Ghana