General Health Information and Medical History 2020
* Required
Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Please check the appropriate box(es) to indicate if you have (or had) the following medical conditions:
*
Please check all that apply.
Allergies
Anxiety & panic disorders
Asthma or hay fever
Bipolar disorder
Celiac disease
Chronic respiratory problems
Depression
Diabetes
Eating Disorders
Fainting spells
Head injury
Heart or circulatory problems
High or low blood pressure
Indigestion (frequent) or ulcer
Hepatitis
Liver or gall bladder problems
Mononucleosis
Obsessive compulsive disorder
Parasites
Post-traumatic stress disorder
Problems of the immune system
Schizophrenia
Seizures/epilepsy
Sexually transmitted infection/sexually transmitted disease
Sinus trouble
Skin disease
Stroke
Substance Abuse & Addiction
Thyroid or other endocrine problems
Tuberculosis
Typhoid Fever
Tonsilitis
No medical conditions
Other:
Required
Please list dates and important information for any medical condition indicated above.
*
Your answer
Please explain which conditions should be taken into consideration for placement purposes.
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For example, food/animal/environmental allergies, proximity to a hospital, etc.
Your answer
In the past I have:
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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
Required
Please explain any boxes marked "yes" in the question above:
*
Your answer
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.
*
Your answer
Emergency Contact Information - Contact Person 1
This person would be contacted in the event of a large-scale emergency such as a natural disaster, as well as in the event of a personal emergency in which you are unable to communicate, or need someone to communicate on your behalf.
Full Name
*
Your answer
Relationship to you
*
Your answer
Phone Number
*
Please indicate country and area code.
Your answer
Country of Residence
*
Your answer
Email Address
*
Your answer
Emergency Contact Information - Contact Person 2
This person would be contacted in the event of a large-scale emergency such as a natural disaster, as well as in the event of a personal emergency in which you are unable to communicate, or need someone to communicate on your behalf.
Full Name
*
Your answer
Relationship to you
*
Your answer
Phone Number
*
Please indicate country and area code.
Your answer
Country of Residence
*
Your answer
Email Address
*
Your answer
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.
*
Your answer
Date
*
MM
/
DD
/
YYYY
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