Medical History
Name
*
First Name
Last Name
Today's Date
*
/
Month
/
Day
Year
Date
Mission Trip Location
*
Uganda
Bolivia
Disaster Relief
Mission Trip Start Date
*
/
Month
/
Day
Year
Date
Please check the conditions that apply to you:
*
Asthma
Cancer
Cardiac Disease
Diabetes
Epilepsy
Hypertension
Psychiatric Disorder
None
Other
Name of Your Doctor
*
First Name
Last Name
Phone Number of Your Doctor
*
Have you been medically released by your doctor to attend this trip?
*
No
Yes
Are you currently taking any medications?
*
No
Yes
If yes, please list all medications you are currently taking.
Please list any allergies to medications, foods, etc.
*
Please list any dietary restrictions you have or any special dietary accommodations you will need during the trip.
*
Do you use tobacco?
*
Please Select
No
Yes
Do you use illegal drugs?
*
Please Select
No
Yes
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Never
Signature:
*
Submit
Should be Empty: