PART I: to Be Completed by the Student (Applicant)

Stonehill College Domestic and International Travel/Study Programs | Pre-Travel Medical Screening Form (Revised 12/4/2013)

Domestic and International Travel programs can be physically and emotionally demanding, and clinical resources may be limited at some locations.Stonehill College hopes that this medical review process will help you to anticipate yourmedical needs and enable you and your clinician to formulate a plan of support and care. After filling out Part I of this form, we ask that you present it to your primary care provider for review and have them fill out Part II. Once you have obtained this documentation from your primary care provider (and mental health provider if applicable), please submit to Health Services for final review of your documentation. Thank you.

PART I: To be completed by the student (applicant)

Name of Applicant: / Program Name:
Applicant Email: / Program Location:
Applicant Phone: / Dates of Program:
Do you have any allergies to medications, foods, insects or pets? If yes, please list:
Are you taking any prescription medication regularly? If yes, please list:
Please list your past medical history and include any current medical problems:
Does your health keep you from participating in any physical activities?
Have you had any diseases, significant injuries, surgeries, or hospitalizations in the past 5 years? If so, please explain.
Have you been under the care of a psychiatrist, psychologist, therapist/counselor in the past 5 years for a mental health issue? Have you ever been prescribed psychiatric medication? If yes, please list.
Is there anything else about your health/medical history that may be a factor in an emergency?
Have you had any of the following in the past 5 years?
 Asthma |  Eating Disorder |  Stomach/Intestinal Problems |  Mental Health Condition |  Diabetes
 Sleep Disorder |  Heart Disease/High Blood Pressure |  Mobility Problems |  Seizure Disorder |  Other
Explain any you have checked:
Stonehill College recommends that you have a discussion with your treatment provider(s) to formulate a plan to support your medical and mental health needs while participating in an off-campus travel program.
Have you discussed your travel with your provider?  YES |  NO
Do you have a plan should you have an acute exacerbation of any of your chronic medical conditions?  YES |  NO |  N/A
Do you have a plan for ensuring that you have prescriptions and supplies for the duration of your program?  YES |  NO |  N/A

I certify that the information I have provided within this form is complete and accurate and I give permission for the information on any page of this form to be shared with College officials and medical providers in connection with my travel program.

Applicant (Student) Signature:______Date:_____/_____/20____

Part II: To be filled out by Applicant’s Primary Care Physician after review of known past medical history and Part I of this form. Check all that apply. (Healthcare provider must be licensed in the U.S. and cannot be an immediate family member.)

 / STUDENT IS CLEARED.
 / There are no medical or mental health contraindications to participation in the program that this student has chosen.
 / Student has treatment plan in place and is stable.
 / Student has a plan for ensuring sufficient supply of prescribed medications and supplies to last through the duration of the program chosen.
 / Student has an allergy to certain medication(s) and/or certain foods.
 / Student has adequate supply of Epi-pens and allergy medications, if needed, with appropriate expiration dates, to treat potential reaction.
 / Student requires additional services to facilitate health, safe participation in the program. Please provide additional information below.
 / STUDENT IS NOT CLEARED.
 / There are medical or mental health contraindications to participation in the program that this student has chosen.
Additional Information:
Name of Licensed Physician/Health Practitioner: / Provide address or place office stamp here:
Signature:
Date:
/ /20 / Phone Number:
( ) -

When Part I and Part II are complete, student should return this form to Stonehill College Health Services

For Stonehill College Health Services Administrative Use Only:
 The required documentation has been reviewed and the documentation supports student’s application for participation in the program.
The required documentation has been reviewed and we find that there may be medical/psychiatric contraindication to participation in the program.
 The student is advised to call Health Services at 508-565-1307 to further discuss.
 The student may not participate without further supporting documentation from their clinician.
The required documentation has been reviewed and the student’s documents indicate that the student has not been cleared for participation in the program.
Notes:______
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Stonehill Clinician Name:______
Stonehill Clinician Signature:______Date:_____/_____/20___