Health Screening Form

Health   S creening    

(To   b e   c ompleted   b y   A pplicant)  

 

____________________________________    

_______________________________   _______________________

 

Last   N ame  

 

 

 

 

First   N ame  

 

 

 

Date   o f   B irth   ( MM/DD/YYYY)  

Gender:                   M ale             F emale                   H eight:   _ __________   ( in   f eet   a nd   i nches)               W eight:   _ ____________   ( in   p ounds)  

Health   H istory                              

(Check   a ll   t hat   a pply)  

Anemia  

Dizziness/Fainting  

Heart   D isease    

Mumps  

Anorexia  

Ear   I nfection  

Hepatitis   A /B/C  

Pregnancy  

Arthritis  

Epilepsy/   S eizures  

Kidney   D isease  

Rheumatic   F ever  

Asthma  

Eye   P roblems  

Malaria  

Scarlet   F ever  

Bulimia    

Gallbladder   P roblems  

Measles  

Tuberculosis  

Chicken   P ox  

German   M easles  

Menstrual   P roblems  

Ulcers  

Depression  

Glandular   F ever  

Migraine/   H eadaches  

Venereal   D isease  

Diabetes  

Other  

If   y ou   c heck   a ny   o f   t he   a bove,   p lease   g ive   d etails   ( including   d ates)   o n   a   s eparate   s heet   o f   p aper.  

Place   a   c heck   m ark   n ext   t o   f ollowing   o rgans   o r   s ystems   i f   t here   a ny   k nown   a bnormalities?  

Cardiovascular  

Head,   e ars   , nose,   t hroat  

Reproductive  

Metabolic  

Respiratory  

Eyes   ( including   g lasses   o r   c ontacts)  

Gastrointestinal  

Skin  

Genitourinary  

Musculoskeletal  

Nervous  

Other  

If   y ou   c heck   a ny   o f   t he   a bove,   p lease   g ive   d etails   ( including   d ates)   o n   a   s eparate   s heet   o f   p aper.  

Do   y ou   s uffer   f rom   a ny   a llergies?    

Allergies    

Describe   r eaction:  

Management   o r   t reatment:  

Hay   F ever  

 

 

Insect   S ting  

 

 

Penicillin  

 

 

Other   d rugs  

 

 

Other:  

 

 

General   Q uestions:    

Is   y our   p hysical   a ctivity   r estricted   i n   a ny   w ay?     Y es  

No      

Do   y ou   h ave   a ny   d ietary   r estrictions?    

Yes  

No  

Do   y ou   h ave   a   c hronic   o r   r ecurring   i llness?    

Yes  

No      

Are   y ou   c urrently   t aking   a ny   m edications?     Yes  

No  

Have   y ou   e ver   b een   t reated   b y   a   p sychiatrist?     Yes  

No      

Have   y ou   e ver   u ndergone   s urgery?    

Yes  

No    

Have   y ou   e ver   r eceived   t reatment   f or   a   n ervous   o r   e motional   i ssue?    

Yes  

 

No  

If   y ou   a nswered   y es   t o   a ny   o f   t hese   g eneral   q uestions   p lease   g ive   f ull   d etails   o n   a   s eparate   s heet   o f   p aper.  

Emergency   C ontact   * *Must   s peak   E nglish**  

Name:   _ _____________________________________   R elationship   t o   A pplicant:   _ ______________________________  

Email:   _ _____________________________________   T elephone:   _ __________________________________________  

 

Are   y ou   a   U S   c itizen?      

Yes                         N o  

Are   y ou   a   J 1   p articipant   c overed   b y   a   d ifferent   i nsurance   t han   t hat   p rovided   b y   y our   s ponsor?                               Y es                         N o  

If   y ou   a nswered   y es,   p lease   g ive   d etails:    

 

 

Carrier   N ame:   _ __________________________________  

Contact   P hone   N umber:   _ ________________________  

Carrier/Plan   N umber:   _ ____________________________                           G roup   o r   P olicy   N umber:   _ _______________________  

I   c ertify   t hat   a ll   i nformation   g iven   i s   t rue   t o   t he   b est   o f   m y   k nowledge,   a nd   I   h ereby   g ive   p ermission   f or   e mergency   m edical   c are   s hould   i t   b e   n ecessary.    

 

_________________________________________________  

 

 

 

_____________________  

Signature    

 

 

 

 

 

 

 

 

Date   ( MM/DD/YYYY)  

 

 

 

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RV3   E ffective   1 2/20/2012