Medical Reference form for Hesed
(Note: Medical Reference Forms will not be accepted if completed by a walk-in clinic (e.g., CVS MinuteClinic), nurse practitioner or physician assistant, and not completed by your Primary Care Physician.)
Email address *
TO THE EXAMING PHYSICIAN:
Your careful attention to this Medical Reference Form is vital. Your patient has applied to participate in a rigorous volunteer work program in Israel. Your medical evaluation of the applicant’s physical condition and mental stability is essential in determining the applicant’s suitability for the project. The applicant will be working in a large hospital and the Israeli medical system requires accurate information for the well-being of both the volunteer and hospital patients. This medical data will also enable medical professionals in Israel to appropriately address any medical emergencies that your patient may face during the project. If you have questions as to the medical or psychological suitability of your patient for such a project, it would be a great disservice to the patient, the volunteer group, and the hospital to approve them.
Patient Last Name *
Your answer
First Name *
Your answer
Age *
Your answer
How long has this applicant been a patient of your practice? *
Your answer
Date of last complete physical exam with lab work and appropriate diagnostics? (A complete physical is required within a 12 month period preceding the date of the trip.) *
Your answer
Medical History and Questionnaire
Medications & Dosage: *
Your answer
Allergies: *
Your answer
History of Severe Injuries and Surgeries: *
Your answer
Physical, Mental, or Emotional Limitations: *
Your answer
Within the past five (5) years, has the applicant been diagnosed with or treated for any medical conditions in the following areas. *
Yes
No
Eyes/Ears/Nose/Throat
Mouth/Teeth
Immune
Cancer/Tumors
Neurological
Transplants
Arthritis
Bones/Muscles/Joints
Psychological
Diabetes/Endocrine
Reproductive
Lung/Respiratory
Digestive/Intestinal
Liver/Kidney/Urinary
If "other" please explain below:
Your answer
For all “YES” answers, provide details in space provided.
Your answer
Does the applicant currently have: *
Yes
No
Any abnormal test or physical examination results
Any health condition, illness or injury that may require treatment
Any use of tobacco products
Any dietary requirements that may be a challenge to foreign work or travel
Any weight or mobility difficulties that may be a challenge to foreign work or travel
Any medical devices, equipment, braces, or prosthesis which are used on a regular basis
Any physical or medical limitation to lengthy air or vehicle travel
Any physical or mental condition that may impact possible roommates
Any restrictions due to physical or mental health conditions
Please explain any “Yes” answers listed in the questions above with Diagnosis/ Treatment, Diagnosis Date, Treatment Status:
Your answer
Please answer the following questions in regard to the patient’s general health and physical condition. *
Yes
No
Is the patient capable of rigorous labor with lifting (30 lbs. or less), twisting, and bending?
Is the patient capable of walking long distances in hot, humid weather?
Is the patient capable of working a full day and work week while standing on their feet?
Does the patient live an active and healthy lifestyle?
Psychological Profile
Conditions imposed by a foreign work program include absence from family and home, close quarter group living, extended hours of travel, new social contacts, and adjustments to cultural differences. The experience is physically and mentally stressful and moves individuals out of their comfort zone.
Please answer the following questions in regard to the patient's general psychological profile: *
Yes
No
Is the applicant a positive, flexible and agreeable person?
Is the applicant capable of working and living with others?
Is there any history of mental disorder or difficulty?
Is there any history of being treated by a psychiatrist, psychologist, or professional counselor?
Is or has the applicant used tranquilizers, anti-psychotics, anti-depressants, etc?
Is there any history of addictions or the use of addictive substances?
Signature for Physician
I have examined the above applicant and ____ Do ____ Do Not consider him/her physically and emotionally qualified to participate in a rigorous foreign work project. *
Physician’s Name: *
Your answer
Physician's Address: *
Your answer
Physician's Phone: *
Your answer
Physician's Fax: *
Your answer
By clicking the Yes, I hereby certify that the statements and answers I am providing in this form are true and correct to the best of my knowledge and belief, and that I understand that statements or information furnished in this application are subject to verification. *
Required
Date: *
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Time: *
Time
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For the patient to complete and sign:
I authorize the leadership of The Friends of Israel Gospel Ministry, Inc. and their assigned representatives to release the above-described medical information to medical facilities or medical practitioners solely for use in my evaluation as an applicant or my medical treatment as a participant in the Hesed Project under the direction of The Friends of Israel Gospel Ministry, Inc.
Name: *
Your answer
Date: *
MM
/
DD
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YYYY
Time: *
Time
:
By clicking the SUBMIT button, I hereby certify that the statements and answers I am providing in this application are true and correct to the best of my knowledge and belief, and that I understand that statements or information furnished in this application are subject to verification.
Important Notice Regarding Immunizations
In past years, Kaplan Medical Center has required specific immunizations. This is no longer a requirement due to the nature of the work. However, we strongly suggest that you seek your doctor’s advice regarding his/her recommendations for beneficial immunizations. You may encounter possible hospital contaminants or other hazards while cleaning or performing manual labor tasks in emergency rooms, patient rooms, kitchens, older buildings, and/or maintenance spaces.
A copy of your responses will be emailed to the address you provided.
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