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. 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):

Signature:
Date:

13. Medical Insurance:
Policy #: