Dear doctor:
The bearer of this letter is a candidate to become a youth volunteer or field staff with Canada
World Youth (CWY) and will stay overseas several months.
Our youth volunteers and field staff will stay in one country in Africa, Asia, Eastern Europe or
Latin America for some months. They may live in areas where medical care is often only
rudimentary and the living conditions are sometimes very difficult. They have to be in
perfect mental and physical health. We therefore urge you to be very thorough and
objective in your examination, as problems considered minor in Canada can prove
disastrous overseas where medical help may be hard to come by.
Your opinion is critical in helping us decide whether or not a candidate is capable of living
in a developing country. We have a great responsibility and your opinion is very
important to us.
Rest assured that your opinion, the medical report you complete, and any comments therein
will be treated as strictly confidential.
Pre-selection medical examination
1. Medical History Form (Part 1): The candidate will give you a medical history form
that should have been already completed.
2. Medical Examination Form (Part 2): We ask you to complete with the candidate the
medical examination form based on your physical and mental examination of the
candidate. If you recommend further tests, those tests will have to be done and results
included in your report before being sent to the CWY medical office
3. It is recommended that all youth volunteers and field staff have a dental examination in
order to avoid any problems during the stay abroad. However, it is not necessary for
them to send us their dental dossier.
4. Sending the forms: Please send the duly completed Medical Examination and History
Forms to us by mail, fax or email at the following coordinates:
Canada World Youth
c/o Medical Office
2330, Notre-Dame St. W., 3rd floor
Montreal (Quebec)
H3J 1N4
Fax: (514)360-3881
medical@cwy-jcm.org
Please send the required information as soon as possible.
IMPORTANT: The candidate will not be considered if the medical forms are
missing or incomplete.
6. Fees: Canada World Youth is not in a position to cover any of the fees of the
examining doctors. It is up to the candidate to pay for the medical examination
if it is not covered by the provincial health insurance plan.
Immunization program and visit to a Travel Clinic
The candidate will also need to receive a series of vaccinations as part of his/her medical
preparation for the overseas stay. We shall send him/her all the necessary information
regarding his/her vaccination program shortly as well as the addresses of Travel Clinics in
his/her region.
If you require further information, please do not hesitate to call or write to our Medical
Office from 9:00 to 12:00 or 1:00 to 5:00, from Monday to Friday, at 514-931-3526
extension 327 or 1-800-605-3526 extension 327, fax: 514-360-3881 and email at:
medical@cwy-jcm.org.
Thank you for your collaboration.
The Medical Consultants of Canada World Youth
Dr Marc Laporta, Dr Louise Poirier and Dr Dominique Trempe
Siège social / Head Office 2330 Notre-Dame O. / Notre-Dame W., 3e étage / 3rd floor
Montréal (Québec) / Montreal, Quebec, Canada H3J 1N4
Tél.: (514) 931-3526 Fax/Téléc.: (514)360-3881
jeunessecanadamonde.org / canadaworldyouth.org
CONFIDENTIAL
MEDICAL HISTORY (PART 1)
(SECTION TO BE COMPLETED BY CANDIDATE)
Important note: Once filled out by the candidate, this form must be given to the physician who
will send it to CWY along with the doctor’s medical examination form
1. NAMES
2. SEX
__________________________________________
LAST NAME(S)
MALE
__________________________________________
GIVEN NAME(S)
OTHER
3. DATE OF BIRTH:
FEMALE


__________ / __________ / __________
DAY
MONTH
YEAR
 SPECIFY_________________
4. PRESENT ADDRESS (NUMBER, STREET, CITY OR TOWN AND PROVINCE)
5. CONTACT INFORMATION
_____________________________________________________
HOME:
_________________________________________________
(_________) ____________ - __________________
AREA CODE
CELLULAR: (_________) ____________ - __________________
AREA CODE
EMAIL: ___________________________________________
6. PROVINCIAL HEALTH INSURANCE NUMBER (MANDATORY):
7. HAVE YOU EVER PARTICIPATED IN AN “OVERSEAS” PROJECT?
(IF YES, PLEASE SPECIFY THE COUNTRY, DURATION AND PURPOSE)
# ____________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PROVINCE: ________________________________
8. EMERGENCY CONTACT
FULL NAME: _______________________________________________ RELATIONSHIP TO THE PERSON : _______________________
TELEPHONE
HOME
CELLULAR
(________) _______ - _____________
AREA CODE
EMAIL : ____________________________________________________
(________) _______ - ____________
AREA CODE
9. THE CANDIDATE IS APPLYING TO CANADA WORLD YOUTH AS :
 YOUTH VOLUNTEER
 STUDENT - SCHOOL/COLLEGE/UNIVERSITY __________________________________________
SPECIFY
 YOUTH LEADERS IN ACTION (YLA; 4-6 MONTHS)
 SHORT YLA (6 WEEKS)
 GLOBAL LEARNER (2-4 WEEKS/2-3MONTHS)
 OTHER (SPECIFY) :_______________________________________________ DURATION: ____________________________
10. HAVE YOU TAKEN ANY OF THE FOLLOWING MEDICATIONS IN THE PAST 2 YEARS?
YES
MEDICATION
NO
TAKEN FOR
NAME OF
MEDICINE
DOSAGE
HOW OFTEN &
HOW LONG ARE
YOU STILL
TAKING IT?
HORMONES
BIRTH CONTROL PILLS
SLEEPING PILLS
« PEP » PILLS (RITALIN, DEXEDRIN…)
TRANQUILLIZERS OR ANTIDEPRESSANT
(EFFEXOR, LUVOX, PROZAC, ZOLOFT,
WELLBUTRIN…)
ANTIPSYCHOTICS (HALDOL OR OTHER…)
OTHER MEDICINES (SPECIFY)
WHEN DID
YOU CEASE
TAKING IT?
11. HAVE YOU EVER HAD OR HAVE YOU NOW: (PLEASE CHECK EACH ITEM) FOR ANY ITEM MARKED "YES", GIVE DETAILS.
CHECK EACH ITEM

Yes
No
CHECK EACH ITEM

Yes
No
CHECK EACH ITEM

Eye trouble
Pain in the chest
Paralysis
Ear, nose, throat trouble
Heart disease
Recurrent back pain
Severe tooth or gum trouble
Low or high blood pressure
Skin disease
Allergies
Dizziness or fainting spells
STI (Sexually Transmitted Infections)
Any reaction to serum or
medicine
Thyroid trouble
Tropical disease
Asthma
Tumor or cancer
Epilepsy
Sinusitis
Stomach trouble
Frequent insomnia
Frequent or severe headaches
Hepatitis (jaundice)
Depression
Migraine
Diarrhea or digestive trouble
Anguish, anxiety, panic attacks
Bronchitis
Kidney trouble
Neurological trouble
Tuberculosis
Arthritis
Other mental or emotional illness
Shortness of breath
Swollen or painful joints
Particular food problems (e.g. anorexia,
bulimia)
Yes
No
12. HAVE YOU EVER: (PLEASE CHECK EACH ITEM) FOR ANY ITEM MARKED « YES » GIVE DETAILS ON NEXT PAGE
CHECK EACH ITEM

Yes
No
CHECK EACH ITEM

Yes
No
CHECK EACH ITEM

Coughed up blood
Noticed blood in your urine
Attempted suicide
Worn glasses or contact lenses
Noticed blood in your stool
Had abnormal laboratory tests results
Had defective hearing
Excessive bleeding tendency
Yes
No
DETAILS :
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
13. FEMALES – DO YOU HAVE MENTRUAL PROBLEMS?
_______________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
LIFE HABITS
YES
NO
QUANTITY AND FREQUENCY
ALCOHOL


___________________________ / ___________________________
DRUGS (PROHIBITED)


14. DO YOU USE?
QUANTITY
FREQUENCY
___________________________ / ___________________________
WHICH ONE(S)
_____________________________________________
Signature
_____________________________________________
Print
FREQUENCY
Date
___________ / ___________ / ___________
DAY
MONTH
YEAR
***
CERTIFICATION AND CONSENT ***
I ACKNOWLEDG THAT I HAVE CAREFULLY READ ALL THE CONDITIONS DESCRIBED BELOW AND DECLARE
MY ACCEPTANCE, AS INDICATED BY MY INITIALS, SIGNATURE AND DATE BELOW.
- I certify that the information given by me in this medical form are true, complete and correct to the best
of my knowledge and belief. _______ (Initial)
- I understand that any misrepresentation or material omission made on this medical form or other
documents requested by Canada World Youth (CWY) voids or nullifies this application and any subsequent
contract (verbal or written). _______ (Initial)
- I will be responsible for all damages that could result from any misrepresentation or material
omission. _______ (Initial)
- I consent and authorize the disclosure of medical information by Canada World Youth Medical Office to
my emergency contact, project supervisor and his/her supervisor(s) regarding my medical condition
when deemed necessary. _______ (Initial)
- I consent and authorize the disclosure of medical information by the doctor(s), hospitals or clinics
mentioned herein, to the medical office of Canada World Youth with a complete confidential transcript of
my medical record. _______ (Initial)
- I understand that no confidential medical information will be released without my explicit written
consent. _______ (Initial)
- I understand that it is my responsibility to inform and advise the CWY medical office in writing to the
following email address: medical@cwy-jcm.org, if any change in my medical record occurs after sending
this medical form. _______ (Initial)
- I understand that acceptance to any CWY Program(s) is conditional on any medical condition covered or
insurable under CWY’s insurance policy. _______ (Initial)
- I understand that CWY reserves the right at all times to re-evaluate and/or terminate my acceptance or
participation in the program for medical reasons. _______ (Initial)
_____________________________________________
Signature of the candidate
_____________________________________________
Print
Date
___________ / ___________ / ___________
DAY
MONTH
YEAR
CONFIDENTIAL
MEDICAL EXAMINATION (PART 2)
(SECTION TO BE COMPLETED BY THE PHYSICIAN)
PRINTED NAME OF PHYSICIAN
ADDRESS
FAX NUMBER
TELEPHONE NUMBER
2. HOW MANY TIMES HAVE YOU SEEN
THIS PERSON IN THE PAST YEAR?
1. HOW LONG HAVE YOU KNOWN THIS
PERSON?
3. DATE OF EXAMINATION
__________ / __________ / _________
DAY
MONTH
YEAR
4. SIGNIFICANT FAMILY HISTORY
5. PAST HEALTH (INCLUDE MAJOR ILLNESS, INJURIES AND SURGICAL PROCEDURES)
6. ALLERGIES
7. MEDICATION
8. PARTICULAR FOOD HABITS
9. HAS THIS PERSON EVER HAD OR DOES THIS PERSON NOW HAVE: (FOR ANY ITEM MARKED “YES”, GIVE DETAILS ON THE NEXT PAGE)
CHECK EACH ITEM 
1.
EYE PROBLEM
4.
E.N.T. PROBLEM
7.
DENTAL PROBLEM
10. FREQUENT, SEVERE HEADACHE
OR MIGRAINE
13. ALLERGIC RHINITIS
16. ASTHMA OR OTHER
RESPIRATORY PROBLEM
19. GASTRIC TROUBLE
22. KIDNEY TROUBLE
25. INTESTINE INFLAMMATORY
DISEASE
28. HEMATOLOGICAL PROBLEM
31. DIABETES
YES
NO
CHECK EACH ITEM 
YES
CHECK EACH ITEM 
NO
2.
HEART DISEASE
3.
TROPICAL DISEASE
5.
HYPOTENSION OR
6.
SKIN DISEASE
9.
JAUNDICE OR HEPATITIS
HYPERTENSION
8.
DIZZINESS, FAINTING
SPELLS
11. HEMORRHOID OR RECTAL
DISEASE
14. UROLOGICAL PROBLEMS
OR NEPHROPATHY
17. HERNIA
20. VARICOSE VEINS
23. THYROID TROUBLE OR
OTHER ENDOCRINOPATHY
26. TUMOR OR CANCER
29. STI (SEXUALLY
TRANSMITTED
INFECTIONS)
32. TUBERCULOSIS OR CLOSE
CONTACT WITH A
TUBERCULOUS PATIENT
12. ATTENTION DEFICIT
DISORDER /
a.
HYPERACTIVITY
15. PARALYSIS
18. IMMUNOSUPPRESSION
21. ARTHRITIS, RHEUMATISM,
JOINT PAIN
24. NEUROLOGICAL TROUBLE
27. EPILEPSY
30. IMPORTANT LOSS OR GAIN
OF WEIGHT
33. CHRONIC BACK PAIN
YES
NO
10. FOR EACH ITEM MARKED ‘’YES’’ IN QUESTION 9 PART 1 TO 33, EXPLAIN FULLY. USE ADDITIONAL SHEETS IF REQUIRED.
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
11. PLEASE COMPLETE THE CHART BELOW.
PHYSICAL
EXAMINATION
NORMAL

 (PLEASE CHECK LEFT WHEN NORMAL)
1. GENERAL
2. EYES (PUPILS, FUNDI, VISUAL FIELDS, OCULAR MOVEMENTS)
3. E.N.T.
4. LUNGS AND CHEST (INCLUDE BREASTS)
5. CVS
6. ABDOMEN (INCLUDE HERNIA)
7. G.-U. SYSTEM
8. RECTAL (HEMORRHOIDS, PROSTATE)
(IF DEEMED NECESSARY BY THE DOCTOR)
9. SKIN, LYMPHATICS
10. BACK AND EXTREMITIES
11. CNS (SENSORY, MOTOR, REFLEXES, EQUILIBRIUM)
12. FEMALES – PELVIC (VAGINAL, RECTAL)
(IF DEEMED NECESSARY BY THE DOCTOR)
HEIGHT
BLOOD PRESSURE
(SITTING)
WEIGHT
BUILD
PULSE
SLENDER 
MEDIUM 
HEAVY 
OBESE

(PLEASE DESCRIBE ANY ABNORMALITIES IN DETAIL IN THIS SPACE.
ENTER PERTINENT ITEM NUMBER BEFORE EACH COMMENT)
MENTAL HEALTH
12. SIGNIFICANT FAMILY HISTORY.
______________________________________________________________________________________________
13. PAST HISTORY
14. PLEASE COMPLETE THE TABLE BELOW.
CHECK EACH ITEM 
YES
A)
IS THE CANDIDATE SUFFERING FROM ANY MOOD DISORDER?
B)
IS HE/SHE HAVING ANY THOUGHT DISORDER OR DELUSIONAL THINKING?
C)
DOES THE PERSON PRESENT HIS / HER IDEAS IN AN ILLOGICAL,
DISCONNECTED MANNER?
D)
FROM A BRIEF EDUCATIONAL, WORK AND SOCIAL HISTORY, DOES THIS
NO
FOR EACH QUESTION MARKED «
YES
», PLEASE EXPLAIN FULLY
IN THE SPACE PROVIDED BELOW OR ON AN ADDITIONAL SHEET.
PERSON HAVE DIFFICULTY IN WORKING TOWARD A GOAL AND COMPLETING
IT?
E)
IS THE CANDIDATE SUFFERING FROM HALLUCINATION OR ILLUSION?
F)
DOES THIS PERSON HAVE ANY TROUBLE WITH:
SLEEPING?
-
ANGUISH, ANXIETY, PANIC ATTACK?
-
DEPRESSION?
-
PERSONALITY DISORDER?
-
EATING DISORDER?
-
BEHAVIOR DISORDER?
G)
HAS THIS PERSON ATTEMPTED SUICIDE?
H)
DOES THIS PERSON DRINK EXCESSIVE ALCOHOL, OR USE MARIJUANA, LSD
& RELATIVES, AMPHETAMINES OR NARCOTICS? (IF YES, INDICATE FREQUENCY
AND QUANTITY)
15. REACTION TO STRESS (PLEASE COMMENT ON HOW YOU FEEL THAT THIS PERSON WOULD ADAPT TO THE STRESSES OF LIVING AND WORKING IN A
FOREIGN COUNTRY AND IN AN UNUSUAL SOCIAL AND CULTURAL SETTING)
16. HAS THIS PERSON ALREADY UNDERGONE A MENTAL ASSESSMENT DONE BY A PSYCHIATRIST, A THERAPIST OR A PSYCHOLOGIST?
YES

NO

18. SUMMARY OF PROBLEMS, DIAGNOSES
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
MANDATORY INFORMATION
19. FOLLOWING
THE PHYSICIAL AND MENTAL EVALUATION OF THIS CANDIDATE AND
CONSIDERING THAT HE/SHE WILL STAY SEVERAL MONTHS ABROAD IN ANOTHER SOCIOCULTURAL CONTEXT AND DIFFICULT SANITARY CONDITIONS, DO YOU THINK

HE/SHE IS ABLE TO TAKE PART IN THIS PROJECT
 HE/SHE IS NOT ABLE TAKE PART IN THIS PROJECT
 THE MEDICAL RECORD SHOULD BE FURTHER REVIEWED BY THE MEDICAL OFFICE OF
CANADA WORLD YOUTH.
SIGNATURE OF PHYSICIAN
DATE
The answers to the above questions will be treated with strict confidentiality
For any questions related to the present form, please do not hesitate to communicate with the CWY medical office at
1-800-605-3526, ext. 327 or at medical@cwy-jcm.org
We thank you for your cooperation.
The Medical Office of Canada World Youth