CADI summer 2013 Health and Allergy History Form
All participants must complete the Health and Allergy History Form in order to participate in the CADI program.
Student information:
,
Last Name
Gender
F
M
DOB:
/day
Excellent
Good
First Name
/mo
ID#
/year
General Health:
My general health is:
Height:
ft/in
Fair
weight:
Poor
Lbs
blood type:
List any recent or continuing health problems:
Are you currently under the care of a doctor or other healthcare professional, including mental health
treatment?
Yes
No
If yes, Doctor’s Name:
Phone:
For what condition(s):
Medical History:
Drug/Food Allergies: List any drug and/or food allergies and briefly describe reaction.
Surgeries: List type and year:
Hospitalizations: List reason and year:
Check if you have ever had any of the following:
Yes
No
Date
Yes
No
Date
Yes
Headaches
Ulcer/Colitis
Back/Joint problems
Epilepsy/Seizures
Asthma/Lung
disease
Diabetes
Cancer/Tumors
High Blood Pressure
Severe allergic
reaction
Heart disease
Thyroid problems
Vision problems
Anemia or Bleeding
Hepatitis/Gallbladder
Bladder/Kidney
disorder
disease
problems
No
Mental Health History:
Have you ever suffered from, been treated for or hospitalized for the following?
Yes/Year(s)
Depression/Anxiety
Substance abuse (alcohol or drugs)
Eating disorder (anorexia/bulimia)
Are you taking/have taken
medication for the above problems?
OTHER conditions?
Please provide an explanation below for any box you have checked .
Date
Devices – Do you wear or use any of the following devices?
Contact lenses or eyeglasses ?
Yes
Hearing aid(s)
Both
Right
Pacemaker ?
Prosthetic joints or devices?
Yes
No
Yes
No
No
Left
If yes, please list:
Other (please explain):
Immunization History – Indicate most recent date:
Date
Date
Polio immunization
Measles, Mumps and Rubella
(MMR)
Tetanus booster or Tetanus/diphtheria booster
Chicken Pox vaccine
Hepatitis A
Meningococcal
Hepatitis B
Typhoid
Yellow Fever
Medications – Participant is responsible for ensuring that all medications are legally permissible abroad.
Are you taking any medications?
Yes
No
If yes, please specify below. Also include any
medication you carry for possible use, e.g. inhaler, bee sting kit, epinephrine.
Med #1 ____________________________________ Dosage _____________________ Specific time each day _________________
Reason for taking____________________________________________________________________________________________________
Med #2 ____________________________________ Dosage _____________________ Specific time each day _________________
Reason for taking____________________________________________________________________________________________________
Med #3 ____________________________________ Dosage _____________________ Specific time each day _________________
Reason for taking____________________________________________________________________________________________________
Licensed Physician/Health Practitioner:
Name of family physician:
Phone:
There are NO medical/psychiatric contraindications to participation with the CADI pre-college program.
Signature:
Date:
Date of last physical exam:
Use this space to provide any additional information about the participant’s behavior and physical,
emotional, or mental health about which CENTRO should be aware.
This form MUST be signed by your Physician/Health Practictioner