William Jessup University Mission Trip/Travel
Medical History/Authorization for Treatment Form
Name
Gender
Age
Birth Date
School Address
Phone (
)
-
Permanent Address
Phone (
)
-
Phone (
Physician
)
-
Medical or Accident Insurance-Name of Company
Policy No
In case of emergency, contact:
Name
Relationship
Address
(Street, City Zip)
Phone (
)
-
**NOTE: IT IS VERY IMPORTANT THAT ALL QUESTIONS ARE ANSWERED ACCURATELY, as
failure to answer thoroughly may put you in extreme danger in an overseas medical or
emotional crisis.
PAST HISTORY---Please check in the space provided if you have or haven’t had the following
conditions. For conditions checked, please describe and indicate the current status in the
space provided.
Yes
Asthma/respiratory problems?
No
Yes
Nose bleeds?
Wheezing/Gasping?
Sinus problems?
Rheumatic fever?
Diabetes?
Heart murmur?
No
Fainting spells?
High blood pressure?
Seizures?
Chest pressure or pain?
Frequent headaches?
Shortness of breath?
Anxiety or Depression?
Heat exhaustion?
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Any loss or serious impairment
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Racing heart or unusual beats?
organs? (kidney, eye)
Stomach/Abdominal pain?
contacts
Nausea?
below)
Vomiting?
skin, etc?)
Back trouble?
medications?
Ear aches?
etc.)
Ringing ears?
physician care now?
Deafness/Hearing difficulties?
Abnormal bleeding tendencies?
Blood Type?
of paired
Do you wear glasses or
Regularly?
Any Allergies: (hay fever,
Allergic to any
(Penicillin, aspirin,
Are you under
What is your
Please comment about any questions which have been checked "Yes":
Click here to enter text.
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(list
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HOSPITALIZATIONS:
Please list reason for any hospitalization(s); give approximate date and length of stay.
Click here to enter text.
MEDICATIONS CURRENTLY TAKEN:
Please list the name of drug, dosage, frequency, and reasons for use.
Click here to enter text.
PRECAUTIONS:
Do you have any physical, emotional, or psychological concerns that may hinder you from
being able to function freely as a member of team in extreme physical or emotional
conditions, cultural discomforts, etc? (these may include, but are not limited to things like
anxiety issues, blackouts, dependence on prescription medications, fears, etc).
Click here to enter text.
AUTHORIZATION FOR TREATMENT:
I,
, the participant, do hereby authorize:
(Team Leader Name) and/or
(Name of
Host Individual) the agent, acting as the team member’s agent, to consent to any x-ray,
examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care or
service, which is deemed advisable and is rendered under the general or specific supervision
of any licensed physician and surgeon, or the medical staff of a licensed hospital, whether
such diagnosis or treatment is rendered at the office of said physician or at said hospital. It
is understood that this authorization is given in advance of any specific diagnosis, treatment,
or hospital care being rendered, but is given to provide authority and power on the part of
the Agent in the event of my disability to give specific consent to any and all such diagnosis,
treatment, or hospital care which the above mentioned physician, in the exercise of his/her
best judgment, may deem advisable. I hereby authorize any hospital, which has provided
treatment to the team member to surrender physical custody of the team member to the
agent upon completion of treatment. I understand that it is important for William Jessup
University to have a thorough understanding of my physical and emotional health and certify
that I have answered the above questions to the best of my knowledge.
Signature Click here to enter text.
Confidential
Date
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2/8/2016