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

Hepatitis A

Hepatitis B

HIV

AIDS

Typhoid

Tuberculosis

Immunization Record *

Yes

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

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

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

Allergy

Reaction

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

Injury/Diagnosis

Previous/Current

System Review

Check the conditions that apply to you

General Well-being *

Yes

Weight Loss

Excessive Fatigue

Sleep Apnea

Anxiety or Depression

Respiratory *

Yes

Asthma/Emphysema

Persistent Coughing

Spitting Blood

Tuberculosis

Difficulty Breathing

Eyes *

Yes

Uses Contacts or Glasses

Blurry Vision

Other

Ears, Nose, Mouth, Throat *

Yes

Hearing Loss

Nose Bleeds

Sinus Problems

Throat Infections

Ear Infections

Endocrinal *

Yes

Diabetes

Low Blood Sugar

Hormone Problems

Thyroid Problems

Dehydration

Cardiovascular *

Yes

Heart Disease

High Blood Pressure

Low Blood Pressure

Irregular Heartbeat

High Cholesterol

Heart Murmurs

Other

Immune *

Yes

Allergies

HIV/AIDS

Immune System Problems

Yes

Anemia

Bruises or Bleeds easily

Other

Psychiatric *

Yes

Anxiety

Depression

Panic Attacks

Sudden Mood Swings

Other

Skin *

Yes

Dry Skin

Rashes

Large or irregular moles

Skin cancer

Eczema

Gastrointestinal *

Yes

Hepatitis

Black or abnormal stools

Gallbladder Disease

Rectal Bleeding

Changes in bowel movement

Constant stomach pain

Gastritis or Ulcers

Other

Sketetal *

Yes

Back pain or Injury

Arm or foot pain

Broken Bones

Joint Pain

Torn or broken tendons

Arthritis

Other

Urinary *

Yes

Blood in the urine

Urinary Tract Infection

Kidney Stones

Abnormal Pap smear

Enlargement of the prostate

Ovarian Cysts

Other

Neurological *

Yes

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