Global Expeditions Health Form
COMPLETING THIS FORM:
1. Parent or Guardian is to complete Parts I-IV. Please note that both the participant and parent/guardian are to sign at the bottom of the form.
2. Physician/health care provider is to review the participant/Student Medical History section and then complete and sign the Physical Examination.
3. Entire completed form AND photocopy of participant’s health insurance card is to be returned to Global Expeditions leaders by February 16th, 2018.
I. Participant Information
Participant Name: ______
Birth Date: ______
II. Parent/Guardian Information
Parent/Guardian Name: ______
Relation to Student: ______
Email: ______
Phone Numbers Home: ______
Cell: ______Work: ______
Parent/Guardian Name: ______
Relation to Student: ______
Email: ______
Phone Numbers Home: ______
Cell: ______Work: ______
III. Participant Insurance Information
Insurance Company: ______
Address: ______
Phone Number: ______Fax Number: ______
Contract Code: ______
Policy Holder: ______
Policy Holder Phone: ______
Policy Number: ______Effective: ______
Have you contacted your insurance provider concerning information on international travel? YES // NO
If so, what type of international coverage does your insurance provider provide? (Describe below.)
Please include a copy of the participant’s health insurance card, front and back, with this form. (Participant should have his/her insurance card with them at all times during the trip.)
IV. Emergency Contacts (if parents are unavailable)
Name/Relationship: ______
Phone: ______
Name/Relationship: ______
Phone: ______
V. Participant Medical History – (To be completed by participant’s physician/health care provider.)
Physician’s Information
Physician’s Name: ______
Physician’s Address: ______
Phone: ______Fax: ______
Is this your primary care provider? YES // NO
Have you ever had: / Yes / NoAllergies (Please list below)
Regular Medication
If “yes,” please give the name and dosage of the medication at the bottom. Also, note whether the medication(s) may be complicated by or cause harm from prolonged heat or sun exposure.
Arthritis
Asthma or Hay Fever
Back Problems
Bleeding Problems
Cancer
Chronic Lung Disease
Diabetes
Eye Defect
Hearing Defect
Heart Disease
High Blood Pressure
Kidney Disease
Learning Disability/Physical Handicap
Nervous or Mental Disorder
Psychological/Emotional Problems
Recurrent Headaches
Rheumatic Fever
Present Condition Requiring Care by a Physician
Reason for Limited Physical Activity
Seizures
Serious Injury
Surgical Operation
Stomach or Intestinal Trouble
Thyroid Disorder
Tuberculosis
Please explain any “Yes” answers below:
Immunization History (To be completed by participant’s physician/health care provider.)
Vaccine / DosesEnter month, day, and year each immunization was given. / Boosters
Diphtheria and Tetanus
Tuberculosis (Required / Result:
Hepatitis B
Measles, Mumps, Rubella
Other
*Tetanus and Diphtheria are usually received in combined vaccinations such as DTP, DTaP, DT, or Td
Which malaria prophylactic will you be taking while in Ghana? Please note, malaria medication is a requirement for this trip.
A Yellow Fever vaccination is a requirement for the trip. You must be able to provide a certificate of proof or you will be denied entry into Ghana.
Report of Physical Examination (To be completed by participant’s physician/health care provider.)
Normal / Abnormal / Not Examined / CommentsHeight (inches)
Weight (pounds)
Pulse
Blood Pressure
Skin
Ears- Hearing dB R L
Nose and Throat
Lymph Glands
Heart – Murmur, etc.
Lung
Abdomen
Genitourinary
Neuromuscular
Are there any special medical problems or concerns, chronic diseases, or medications which might require restriction of activity such as excessive exposure to heat and/or sun, or which might affect his/her participation in certain activities? If so, please specify:
Physician Name (print): ______
Signature of Examiner: ______Date: ______
VI. Participant Signatures
The statements and answers as recorded above are full, complete, and true to the best of my knowledge and belief. I understand that any false or misleading statements may cause termination of application and/or dismissal of participant even after the program has commenced.
I authorize the physician or other person to disclose any knowledge or information pertaining to my son/daughter/ward’s health to Project Wisdom Global Expeditions for whom this examination is performed.
Parent/Guardian Name: ______
Parent/Guardian Signature: ______
Date: ______
Participant Name: ______
Participant Signature: ______
Date: ______