Health Inventory Medical Form
NOTE: This is a confidential record of your medical history and will only be used in case of emergency while you are traveling with Extend Global. You will be asked to fill out a new form for each trip.
* Please complete the Health Inventory Form in one sitting. Do NOT leave and come back, it will NOT save. The form will take approximately 15 minutes to complete. You will need physician information, insurance information, and special or prescription medication information. Please allow enough time to completely finish the form before submitting.
Personal Information
Last Name
Your answer
First Name
Your answer
Middle Name
Your answer
Gender
Date of Birth
MM
/
DD
/
YYYY
Address
Your answer
City:________ State:________ Zip:________
Your answer
Phone Number
Your answer
Marital Status
Employed by or Student of
Your answer
Phone Number
Your answer
Address
Your answer
City:________ State:________ Zip:________
Your answer
In Case of Emergency
Other Nearest relative at Home
Your answer
Relationship
Phone Number
Your answer
Name of Another Person
Your answer
Relationship
Phone Number
Your answer
Name of Physician
Your answer
Phone Number
Your answer
Address
Your answer
City:________ State:________ Zip:________
Your answer
Insurance Information
Name of Insurance
Your answer
Coverage
Group Number
Your answer
Certificate Number
Your answer
Medicare Number (If Applicable)
Your answer
Policy Issued in what State
Your answer
Policy Holder's Name
Your answer
Phone Number
Your answer
Will this policy cover you over seas?
Personal History
NOTE: This is a confidential record of your medical history and will only be used in case of an emergency.
Have you ever had any of the following?
Yes
No
High or Low Blood Pressure
Gout
Diabetes
Kidney Disease or Stones
Bladder Disease
Anxiety or Depression
Appendicitis
Allergies/Sinus problems
Asthma/Persistent cough
Bleeding Disorder
Convulsions/fainting
Epilepsy/convulsion/fainting
Eye/Ear problems
Frequent ear infections
Gall Bladder problems
Heart defect/disease
Hernia
Hives or Eczema
Cancer
Migraine Headaches
Nervous Breakdown
Do you smoke?
Hypertension
Hyperactivity/ADD/ADHD
Infectious disease
Insect stings allergy *Anaphylaxis
Joint/back or limb pain
Arthritis or other conditions
Kidney or liver disease
Menstrual problems
Nervous condition/depression
Nose problems/Bleeding
Physical Disability
Serious illness
Serious injury
Skin/gland problems
Sleepwalking
Stomach/bowel problems
Tuberculosis
Ulcers (stomach/intestines)
Mumps/Chicken Pox
Emotional problems
Swelling of hands, feet or ankles
Abnormal X-rays/ blood-work results
Learning Disabilities
Are you allergic to any of the following drugs?
Yes
No
Mycins or other Antibiotics
Latex
Penicillin or Sulfa
Aspirin, Codeine, or Morphine
Other (Please List)
If Other, Please List Here
Your answer
Family History
Father's Name and Age (If Living)
Your answer
Health (i.e. good, poor, etc.)
Your answer
Age at Death (If Deceased) and Cause (If Known)
Your answer
Mother's Name and Age (If Living)
Your answer
Health
Your answer
Age at Death (If Deceased) and Cause (If Known)
Your answer
Sibling(s) Name and Age (If Living)
Your answer
Health
Your answer
Age at Death (If Deceased) and Cause (If Known)
Your answer
Child/Children's Name and Age (If Living)
Your answer
Health
Your answer
Age at Death (If Deceased) and Cause (If Known)
Your answer
Check if any blood relative has ever had any of the following?
Yes
No
Cancer
Mental Illness
Asthma
Stroke
Heart Trouble
High Blood Pressure
Diabetes
Tuberculosis
Birth Defects
Who and which condition(s)?
Your answer
Explain any “Yes” items from the checked list or family history above and list any other problems, including the diagnosis, date of injury or illness, hospital, length of hospitalization, name of doctor, etc. List any exposure to infectious disease in the month prior to departure.
Your answer
Special or Prescription Medications
Please list any medication being taken or prescribed for occasional use including the name and phone number of the prescribing physician, dosage, consumption rate and interval.
Name of Medication/ Dosage/ Frequency/ Prescribing Physician & Number
Your answer
Special Restrictions (Chronic or recurring illness and treatment which may be needed)
Your answer
Dietary modifications require physician’s written instructions to be given to Extend Global staff three (3) weeks prior to the departure.
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