• Living Hope International CONFIDENTIAL HEALTH FORM

    Please fill out this form to help us get to know your medical history for your upcoming Quest Internship or your stay as a missionary with Living Hope International.

  • Personal Information

  • Date*
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  • Birthdate*
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  • Gender*
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  • General Health Information

  • Rate your physical health*
  • Do you have any objection to using medical services in Mexico?*
  • Are you pregnant?*
  • If yes, when is your due date?
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  • Are you planning on delivering in Mexico?

  • Medical Emergency Contact Information

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  • Insurance Information

  • Personal accident/health travel insurance (required). Please provide copy of policy or insurance card.

  • Does it include medical evacuation?*

  • Medical History

  • Childhood Diseases*
  • Have you ever had any of the following communicable diseases?*
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  • Immunization Record*
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  • Are you taking any medications?*

  • Please list all the medications you are currently taking (including contraceptives, laxatives, aspirin, vitamins, etc...)

  • Medications*
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  • Have you researched to make sure you can purchase all necessary medical equipment and medications during your stay in Mexico?
  • Please list all the surgeries and hospitalizations you have had*
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  • Please list the type of allergies you have and the reaction you experience*
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  • What kind of injuries have you had in the past or other health issues diagnosed by the doctor*
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  • System Review

    Check the conditions that apply to you
  • General Well-being*
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  • Respiratory*
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  • Eyes*
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  • Ears, Nose, Mouth, Throat*
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  • Endocrinal*
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  • Cardiovascular*
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  • Immune*
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  • Psychiatric*
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  • Skin*
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  • Gastrointestinal*
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  • Sketetal*
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  • Urinary*
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  • Neurological*
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  • Social

  • Have you ever intentionally hurt yourself or had suicidal thoughts?*
  • Have you had or do you have an eating disorder?*
  • Did or do you smoke or chew tobacco?*
  • Did or do you drink alcohol?*
  • Did or do you use drugs?*
  • Are you sexually active?*
  • Have you been tested or diagnosed with any sexually transmitted diseases?*
  • Do you have any diseases or conditions that weren't listed in the form?*

  • Work Ability

  • Are you able to complete daily activities?*

  • Do you have any family, cultural, or physical factors that could affect your health care options?*

  • Today's Date*
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