M2: Short-Term Missions Medical Online Form

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
Birthdate *

Month Day Year Date Picker Icon
Team/Group Name *
Gender *

Male Female

Address *

Please list all of the medications you are currently taking (including vitamins, birth control, etc...) *

Please list all allergies and what kind of reactions you have *

Please list any medical conditions *

Blood Type *
Not sure? Enter: Note sure
Please review the following link for the Center for disease and Controls recommendation on Vaccines when traveling to Mexico: https://wwwnc.cdc.gov/travel/destinations/traveler/none/mexico
Should be Empty:

Emergency Contact