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): ___________________________________________________________________________

Any physical handicaps, health conditions, or dietary needs which require special attention?

Yes []; No []; If Yes, please specify: _______________________________________________

Do you have a history of emotional instability or psychiatric treatment? Yes []; No []

If Yes, please specify: __________________________________________________________

Are you Overweight? Yes []; No [].

Are you Underweight? Yes []; No [].

If you answered Yes to the above two questions,

Please indicate your weight in pounds: _____over; _____under.

What is your Blood type: ____

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

 

FAMILY HISTORY

Have any of your relatives ever had any of the following, and if so what is the relationship to you.

Tuberculosis - Yes []; No []; In relation to you: ________________________________________

Arthritis - Yes []; No []; In relation to you: ___________________________________________

Diabetes - Yes []; No []; In relation to you: ___________________________________________

Stomach Disease - Yes []; No []; In relation to you: ____________________________________

Kidney Disease - Yes []; No []; In relation to you: _____________________________________

Asthma Hay Fever - Yes []; No []; In relation to you: ___________________________________

Heart Disease - Yes []; No []; In relation to you: ______________________________________

Convulsion Epilepsy -Yes []; No []; In relation to you: __________________________________

Hypertension - Yes []; No []; In relation to you: _______________________________________

Cancer - Yes []; No []; In relation to you: ____________________________________________

 

Have you ever had any of the following communicable diseasers:

Chickenpox - Yes []; No [];

Pertussis - Yes []; No [];

Measles (Rubella) - Yes []; No [];

Scarlet Fever - Yes []; No [];

Measles - Yes []; No [];

Tuberculosis - Yes []; No [];

Mumps - Yes []; No [];

Other ( Specify ):______________________________________________________________

TO THE PHYSICIAN

Name of applicant: _____________________________________________________________

The above person has applied to be a Student 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, fill out the portion

below, and make any additional comments.

Blood Pressure: ______________________

Pulse: ______________________________

Weight: _____st. _____lb. (_____kg)

Height:_____ft. _____inch. (_____cm)

 

Are there any abnormalities of the following systems? If Yes, Please describe

Ears, Nose, Throat - Yes []; No []. _________________________________________________

Eyes - Yes []; No []. ____________________________________________________________

Neurological - Yes []; No []. ______________________________________________________

Cardiovascular - Yes []; No []. ____________________________________________________

Respiratory - Yes []; No []. ______________________________________________________

Musculoskeletal - Yes []; No []. ___________________________________________________

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

Yes []; No [], if yes please Specify: _________________________________________________

Please list any significant medical and / or psychiatric history: __________________________

____________________________________________________________________________

Please add here any additional comments regarding the applicant's health or special limitations

affecting physical, mental of emotional capabilities: __________________________________

____________________________________________________________________________

Would he /she be able to walk 1-4 miles per day? Yes []; No [].

Please attach any additional comments to this sheet.

Physician recommendation: Acceptable without limitations []; Acceptable with limitations [];

Should remain in areas where adequate medical care is provided []; Not acceptable [].

 

Doctor's Name (please print): ___________________________________________________

Address: ____________________________________________________________________

Doctor's Signature: ________________________________ Date : _____________________

Tel: __________________ Fax: ____________________ Email: _______________________

 

CONSENT FOR TREATMENT

I / we hereby agree to the performance of such treatment, anesthetics, and operations as in the

opinion of the attending physican is deeming necessary on the above-named person.

Applicant signature: _________________________________ Date : _____________________

Signature of Witness: ________________________________ Date : _____________________

Name and Relationship to Applicant: _______________________________________________

 

LIABILITY RELEASE

I / we hereby release YOUTH WITH A MISSION, LTD., its agent, employees, and volunteer

assistants from any liability whatsoever arising out of any injury, damage, or loss which may be

sustained by said person during the course of involvement with YOUTH WITH A MISSION, LTD.

Applicant signature: _________________________________ Date : _____________________

Signature of Witness: ________________________________ Date : _____________________

Name and Relationship to Applicant: _______________________________________________