Health Form

Name: Birth Date:

Email Address:

1. When did you last have a complete physical exam (year)?

2. How do you appraise your present health? ExcellentGoodBelow Par

3. Have you ever been treated for any major physical ailments? YesNo. If so, please specify what and when:

4. Do you have any chronic or recurring health problem(s)? YesNo. If so, please specify:

5. Do you have a condition that requires a special diet? YesNo.

6. Do you have any of the following (please Check):
allergiesasthmadiabetesstomach upsetsheart conditionfrequent coldsmedication reaction

7. Are you currently under-going care or treatment for any physical ailment or physical condition (including pregnancy)? YesNo

8. Are you taking any prescription medication? YesNo. If so, please explain:

9. Will you be taking this medication on your trip? YesNo. If so, bring an extra supply in case of delay or loss of prescription. Please specify type and use:

10. Have you suffered from or received treatment for emotional or mental illness? YesNo. If so, please explain:

11. In case of an emergency away from home, what doctor (knowledgeable about your health) should be contacted?

Doctor’s Name:
Address:
City:
State:
Zip:
Phone:

12. I understand and acknowledge that participation in activities may involve risk of injury, illness, or unforeseen medical conditions. By signing this form, I voluntarily assume all risks and agree to release and hold harmless Foursquare International Church of the Foursquare Gospel, Hany Asaad, or Diana Asaad, its staff, leaders, volunteers, affiliates, and representatives from any and all liability, claims, or legal actions, including but not limited to those arising from negligence, that may result from participation or medical treatment.In case of an emergency, I hereby authorize any necessary medical treatment by proper medical personnel in the country that I am visiting. (If under 18, signature of parent or legal guardian):

I certify that all medical information provided is accurate to the best of my knowledge.

Signature:
Date:

13. Medical Insurance:
Policy #: