Living Hope International - Long-Term Missions Medical Form

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 *

Month Day Year
Full Legal Name(as appears on birth certificate/passport) *

First Name Middle Name Last Name
Birthdate *

Month Day Year
Gender *

Male Female
Personal Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
General Health Information
Blood Type *
Height *
Weight *
Rate your physical health *

Very Good Good Average Below Average Other
Do you have any objection to using medical services in Mexico? *

Yes No
If yes, please explain:
Are you pregnant? *

Yes No
If yes, when is your due date?

Month Day Year
Are you planning on delivering in Mexico?

Yes No
Medical Emergency Contact Information
Emergency Contact Name *

First Name Last Name
Emergency Contact Relationship *
Emergency Contact Phone Number *

Area Code Phone Number
Alternate Phone Number

Area Code Phone Number
Emergency Contact E-mail *
Insurance Information
Personal accident/health travel insurance (required). Please provide copy of policy or insurance card.
Company *
Name on Policy *
Policy Number *
Does it include medical evacuation? *

Yes No
Which hospital would you like us to coordinate with in the USA in case of a medical evacuation? *
Medical History
Childhood Diseases *

Chickenpox Measles Mumps Rubella

Have you ever had any of the following communicable diseases? *

	Yes	No
Hepatitis A
Hepatitis B
HIV
AIDS
Typhoid
Tuberculosis

Immunization Record *

	Yes	No	Date (Month/Year)
BCG(tuberculosis
DPT.Td (series of 3)
MMR
Polio (series of 3)
Tetanus Booster
Typhoid (series of 3)
Hepatitis A (series of 2)
Hepatitis B (series of 3)

Are you taking any medications? *

Yes No
Please list all the medications you are currently taking (including contraceptives, laxatives, aspirin, vitamins, etc...)

Medications *

	Medications	Dosage	Frequency	Period of Use
1
2
3
4
5

How many months supply will you be bringing with you?
Have you researched to make sure you can purchase all necessary medical equipment and medications during your stay in Mexico?

Yes No

Please list all the surgeries and hospitalizations you have had *

	Year	Reason	Duration of Hospitalization
1
2
3

Please list the type of allergies you have and the reaction you experience *

	Allergy	Reaction
1
2
3
4
5

What kind of injuries have you had in the past or other health issues diagnosed by the doctor *

	Injury/Diagnosis	Previous/Current
1
2
3
4
5

System Review

Check the conditions that apply to you

General Well-being *

	Yes	No
Weight Loss
Excessive Fatigue
Sleep Apnea
Anxiety or Depression

Respiratory *

	Yes	No
Asthma/Emphysema
Persistent Coughing
Spitting Blood
Tuberculosis
Difficulty Breathing

Eyes *

	Yes	No
Uses Contacts or Glasses
Blurry Vision
Other

Ears, Nose, Mouth, Throat *

	Yes	No
Hearing Loss
Nose Bleeds
Sinus Problems
Throat Infections
Ear Infections

Endocrinal *

	Yes	No
Diabetes
Low Blood Sugar
Hormone Problems
Thyroid Problems
Dehydration

Cardiovascular *

	Yes	No
Heart Disease
High Blood Pressure
Low Blood Pressure
Irregular Heartbeat
High Cholesterol
Heart Murmurs
Other

Immune *

	Yes	No
Allergies
HIV/AIDS
Immune System Problems

	Yes	No
Anemia
Bruises or Bleeds easily
Other

Psychiatric *

	Yes	No
Anxiety
Depression
Panic Attacks
Sudden Mood Swings
Other

Skin *

	Yes	No
Dry Skin
Rashes
Large or irregular moles
Skin cancer
Eczema

Gastrointestinal *

	Yes	No
Hepatitis
Black or abnormal stools
Gallbladder Disease
Rectal Bleeding
Changes in bowel movement
Constant stomach pain
Gastritis or Ulcers
Other

Sketetal *

	Yes	No
Back pain or Injury
Arm or foot pain
Broken Bones
Joint Pain
Torn or broken tendons
Arthritis
Other

Urinary *

	Yes	No
Blood in the urine
Urinary Tract Infection
Kidney Stones
Abnormal Pap smear
Enlargement of the prostate
Ovarian Cysts
Other

Neurological *

	Yes	No
Disorientation
Fainting Spells
Dizziness
Convulsions
Headaches
Balance/Coordination Problems
Language Problems
Memory Problems
Other

Describe further about the conditions marked other
Social
Have you ever intentionally hurt yourself or had suicidal thoughts? *

Yes No
Have you had or do you have an eating disorder? *

Yes No
If yes, what kind?
Did or do you smoke or chew tobacco? *

Yes No
Did or do you drink alcohol? *

Yes No
Did or do you use drugs? *

Yes No
Are you sexually active? *

Yes No
Have you been tested or diagnosed with any sexually transmitted diseases? *

Yes No
If yes, what kind(s) and how long ago?
Do you have any diseases or conditions that weren't listed in the form? *

Yes No
Work Ability
Are you able to complete daily activities? *

Yes No
Do you have any family, cultural, or physical factors that could affect your health care options? *

Yes No
I verify that the information provided above is true. *

Yes
Today's Date *

Month Day Year
Signature *

Clear
Any other details or information you wish to add that may affect your visit?
Should be Empty:

Living Hope International CONFIDENTIAL HEALTH FORM

Personal Information

General Health Information

Medical Emergency Contact Information

Insurance Information

Medical History

System Review

Social

Work Ability