Medical History
First Name
*
Last Name
*
Mission Trip
*
Please Select
Belize
Costa Rica
Nepal
South Africa
Uganda
E-mail Address
*
Under 18?
*
Yes
No
Section A: Family Medical History
Do your parents, grandparents, or siblings, have any of the following conditions?
Heart Disease
*
Yes
No
Mental Illness
*
Yes
No
Depression
*
Yes
No
Diabetes
*
Yes
No
Hypertension
*
Yes
No
If you answered "Yes" to any of the above questions, explain who has the illness:
*
Section B: Personal Medical History
Date of your last physical exam
*
Name of attending physician
*
List all surgical operations or hospitalizations you have undergone (include the date, procedure, and reason):
*
List any remaining effects from the above procedures:
If you have been hospitalized more than three times, please give an explanation:
Please provide any details pertaining to your physical, mental, or emotional health not covered by the above questions:
*
Section C: Childhood Immunizations
Mumps/Measles/Rubella: Up To Date?
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Yes
No
Year Received
Diphtheria/Pertussis/Tetanus: Up To Date?
*
Yes
No
Year Received
Polio: Up To Date?
*
Yes
No
Year Received
Section D: Medical Checklist
Check the corresponding box if you have been treated by a doctor for any of the following:
Asthma or chronic wheezing
Chronic persistent cough or shortness of breath
Cysts, tumors or growths of any kind, hernia or rupture
Cancer
Any skin disorder or disease other than acne
Goiter, thyroid ailment, high or low metabolism
Diabetes or Hypoglycemia (low blood sugar)
Tuberculosis
Rheumatism, gout, arthritis, or other forms of swollen painful joints
Severe knee injury or problems
Intestinal or bowel problems
High blood pressure, heart murmur, or other cardiac problems
Persistent, recurring indigestion, stomach or duodenal ulcers
Mental health counseling or psychiatric treatment
Fainting spells, epilepsy, or seizures
Parkinson's disease
Anemia or other blood disorder
Serious bodily injury
Thyroid ailment
Severe allergic reactions to food, medicines, bee/wasp stings, or any other insect bites
Any test results indicating exposure to the AIDS virus
Gall bladder stones or colic
Pregnancy
Emphysema or other lung/respiratory problems
Chronic/recurrent ear or eye problems
Impairment of hearing or vision, Menier"s Disease, cataracts, or glaucoma
Jaundice, cirrhosis or other liver problems
Albumin, blood or pus in the urine-painful or frequent urination or kidney problems
Chronic back pain, back injury or surgery, sciatica, scoliosis, or other bone or joint disorder
Vein or circulatory trouble
Severe migraine headaches
Abnormality of the reproductive systems, prostate problems, breast disorder, menstrual disorders, or venereal disease
Any other disease, condition, or disability not listed above
Did you currently have or have you ever been treated for any of the conditions above?
*
Yes
No
If any of the above items are checked, please explain and specify the details:
*
I have completed this medical information form by answering all questions honestly and accurately. I further verify that all information being submitted is complete and correct. Signed:
Applicant e-Signature
*
Date
*
-
Month
-
Day
Year
Date
Required if applicant is under 18 years of age:
Parent/Guardian e-Signature
Date
-
Month
-
Day
Year
Date
Health Insurance Information
All participants in the Believers World Outreach Missions Program are required to have personal health insurance coverage that extends from the first day of the mission trip to the last day of the mission trip. If the participant will be attending an international mission trip, the health insurance policy must cover the individual out of the country as well as while they are traveling domestically. If the individual's present insurance provider does not include overseas coverage, then obtaining a temporary insurance plan that will cover out of the country for the duration of the mission trip is mandatory.
Name of Insured Individual
*
Health Insurance Company Name
*
Policy Number
*
Does this policy cover you in the mission location as required?
*
Yes
No
If you are not sure if you are covered by your current policy, please contact your provider before proceeding with this form. If your health insurance policy does not cover you in your mission location in case of an emergency, you are required to purchase a policy online before proceeding with this form.
I agree that I have provided complete and accurate information regarding my health insurance policy and coverage, and I have met the requirements for participation set by Believers World Outreach:
Applicant e-Signature
*
Date
*
-
Month
-
Day
Year
Date
Required if applicant is under 18 years of age:
Parent/Guardian e-Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: