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 / No
Allergies (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 / Doses
Enter 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 / Comments
Height (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: ______