Brownsville Mission Trip 2008
HEALTH REGISTRATION FORM
(Please Print)
THE INFORMATION YOU PROVIDE IS CONFIDENTIAL. THIS COMPLETED FORM IS REQUIRED FOR YOU TO GO ON THE TRIP. THE HEALTH HISTORIES
OF THE TEAM MEMBERS WILL BE HELD BY THE TEAM PHYSICIAN AND WILL BE USED IN THE EVENT OF A MEDICAL EMERGENGY ON THE MISSION
TRIP. THIS IS STRICTLY FOR YOUR PROTECTION.
Today’s date:
Date Received:
MISSIONER’S INFORMATION
Missioner’s last name:
First:
 Mr.  Mrs.  Dr.
 Miss  Ms.
Middle:
Marital status (circle one)
Single / Mar / Div / Sep / Wid
Name as it appears on your passport:
Passport no.:
Birth date:
/
Blood Type:
/
Street address:
Home phone no.:
State:
ZIP Code:
Employer:
Health Insurance Company:
)
Cell phone no.:
(
Occupation:
Sex:
M F
(
City:
Age:
)
Email address:
Address:
Policy/Group #
Phone no.:
(
Are you insured by MedJet:
In case of emergency contact:
Name:
)
 Yes  No
 No health insurance
Address:
Relationship:
Best phone no. to reach:
2nd phone no. to reach:
(
(
)
Email address:
)
DOCTOR INFORMATION
(Please make a copy of your insurance card FRONT & BACK and attach to this form.)
Primary Health Care Provider:
Specialty:
Address:
Office phone no.:
(
Specialist provider #1 (Pulmonoloist,
Cardiologist, etc) Name:
Specialty:
Address:
Office phone no.:
(
Specialist provider #3 (Endocrinologist,
Gastroenterologist, etc) Name:
Specialty:
Address:
ALLERGY INFORMATION
Do you have any allergies to drugs, insects, food or other?  Yes
Drug Allergy #1
Drug Name:
 No
Reaction (hives, rash, anaphylaxis, etc.):
)
Office phone no.:
(
If you have additional specialist please list on separate sheet of paper.
)
)
Drug Allergy #2
Drug Name:
Insect Allergy #1
Insect Type:
Insect Allergy #2
Insect Type:
Food Allergy #1
Food Type:
Food Allergy #2
Type:
Other Allergy #1
Type:
Other Allergy #2
Type:
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Reaction (hives, rash, anaphylaxis, etc.):
Have any reactions ever required emergency room care? Please list all allergies, if needed please use separate sheet of paper.
CURRENT HEALTH PROBLEMS
Problem #1 (ie diabetes, high blood pressure):
Medicine you are taking for this:
Problem #2 (ie diabetes, high blood pressure):
Medicine you are taking for this:
Problem #3 (ie diabetes, high blood pressure):
Medicine you are taking for this:
Please use additional sheets of paper for any additional problems you feel the Team Doctor(s) should know about.
 Asthma  Angina  Diabetes  Migraines  Ulcers  Bleeding abnormalities  Kidney Stones  Gall Stones  Seizures/Epilepsy
 Alcohol/drug Addition  Heart Disease  Hearing Disorder  Hypertension  Orthopedic Condition  Skin Disorder
 Eye/Vision Disorder
Psychiatric Disease:
 Bipolar  Schizophrenia  Anxiety  Depression
Blood Pressure average Reading:
 Thyroid Disease
 High/low Blood Pressure
Diabetic last HgbA,C:
Please explain any of the above:
Past Major Surgery #1
Date:
Surgery:
Past Major Surgery #2
Date:
Surgery:
Past Major Surgery #3
Date:
Surgery:
MEDICATIONS
Please list all PRESCIPTION medications you are take (including the ones listed above):
Name of Drug:
Dosage:
Frequency:
Purpose:
Please list all OVER-THE-COUNTER medications you are take (including the ones listed above AND vitamins):
Name of Drug:
Dosage:
Frequency:
Purpose:
Tetanus shot is required for all Mission Trips.
Tetanus Shot:
 Yes
Date:
Hepatitis A Inoculation:
 Yes  No
Date:
Typhoid Immunization:
 Yes  No
Date:
Hepatitis B Inoculation:
 Yes  No
Date:
Other Information You would like us to know: