Participant Health History Form
Participant Health History Form:

Please fill out this form as completely as possible to help us keep you safe and healthy during your trip with the Tandana Foundation.  Once you have completed the form, press the submit button at the bottom of the page.  Please do not reply to this email.
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First Name *
Last Name *
Which Tandana program or internship are you participating in? *
Age
Date of Birth *
MM
/
DD
/
YYYY
Height
Weight
Respiratory Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Anaphylactic
Do you have a history of treatment for this condition? If yes, please explain below.
Allergy
Do you have a history of treatment for this condition? If yes, please explain below.
Asthma
Do you have a history of treatment for this condition? If yes, please explain below.
Do you smoke?
Do you have a history of treatment for this condition? If yes, please explain below.
Bleeding/ Blood Disorder
Do you have a history of treatment for this condition? If yes, please explain below.
Cardiac Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Diabetes
Do you have a history of treatment for this condition? If yes, please explain below.
Sickle Cell Trait
Do you have a history of treatment for this condition? If yes, please explain below.
Dietary Concerns
Do you have a history of treatment for this condition? If yes, please explain below.
Menstrual Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Strains/ Sprains/ Fractures
Do you have a history of treatment for this condition? If yes, please explain below.
Knee/ Ankle Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Back Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Mental Health Disorder
Do you have a history of treatment for this condition? If yes, please explain below.
Learning Disorder
Do you have a history of treatment for this condition? If yes, please explain below.
Neurological Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Gastrointestinal Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Urinary/ Reproductive Problems
Do you have a history of treatment for this condition? If yes, please explain below.
Surgery
Have you had surgery? If yes, please explain below.
Medications
Are you currently taking any medications? If yes, please explain below.
Current Medications
Please list current medications and their purpose
Please explain any medical conditions you mentioned above.
Date of last tetanus immunization
I have answered this Health History questionnaire accurately and completely. I understand that my medical history is a very important factor in my participation and safety in this program. I understand that certain medical or physical conditions which are known to me, but that I do not disclose, may result in serious injury to me. If any of the above conditions change, I will immediately inform TTF of those changes. All aspects of my relationship with TTF will be governed by Ohio law, and any mediation, suit, or other dispute with TTF must be filed or entered into only in Ohio. *
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