General Health Information and Medical History 2019
Date of Birth
Please check the appropriate box(es) to indicate if you have (or had) the following medical conditions:
Please check all that apply.
Anxiety & panic disorders
Asthma or hay fever
Chronic respiratory problems
Heart or circulatory problems
High or low blood pressure
Indigestion (frequent) or ulcer
Liver or gall bladder problems
Obsessive compulsive disorder
Post-traumatic stress disorder
Problems of the immune system
Sexually transmitted infection/sexually transmitted disease
Substance Abuse & Addiction
Thyroid or other endocrine problems
No medical conditions
Please list dates and important information for any medical condition indicated above.
Please explain which conditions should be taken into consideration for placement purposes.
For example, food/animal/environmental allergies, proximity to a hospital, etc.
In the past I have:
Please check the box next to the appropriate question(s) if your answer is "yes".
Been hospitalized or had surgery
Had a significant medical condition not listed above
Had a significant psychological or emotional condition not listed above
None of the above
Please explain any boxes marked "yes" in the question above:
In an instance where an English Opens Doors Program staff member needs to assist you in an emergency, please list any information or relevant family history that an EODP staff member should relay to medical professionals or emergency personnel on your behalf.
By typing my name below, I hereby certify, under penalty of exclusion/dismissal from the Program, that the information provided in this document is true and accurate.
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