M2: Short-Term Missions Medical Online Form
This form is a combination of medical factors such as medications and/or allergies LHI should be aware of to ensure a safe and healthy visit, as well as the appropriate course of action if medical attention is needed.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
STM Group Name
*
Group Leader's Full Name
*
First Name
Last Name
Gender
*
Male
Female
Travel Insurance Information
Company
*
Policy Number
*
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Information
List all of the medications you are currently taking (including vitamins, birth control, etc...)
Medication
Dosage
Frequency
Duration
1
2
3
4
5
6
7
8
List all allergies (including dietary restrictions) and what kind of reactions you have
Allergy
Reaction
Treatment
1
2
3
4
5
List any medical conditions
Condition
Past/Present
1
2
3
4
5
Submit
Should be Empty: