Cisv International Programme Participant Health Information Form Page 2
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5PART B: CURRENT MEDICATIONS AND NEEDS
If there are any special needs or allergies, please send this page (or send the information separately) to the programme staff in
advance of the programme.
Name of Participant:
Sending National Association:
Diet
No
Do you require a special diet?
Yes
If yes, please give details:
Are there any foods that you
No
Yes
cannot or should not eat?
If yes, please give details:
Allergies
Do you have allergies to:
No
Food
Yes
If yes, please specify:
No
Bee stings or insect bites
If yes, please specify:
Yes
No
Medicines
Yes
If yes, please specify:
No
Others
If yes, please specify:
Yes
Do you have to carry an
No
If yes, please specify contents:
Yes
anaphylaxis-set with you?*
What medications can you be given for an allergic reaction?
*If you need one, please remember to bring your anaphylaxis-set with you.
Medications
Do you take any medications?* Please include non-prescription medications or remedies to avoid any misunderstanding.
If it is a prescription,
Brand Name
Generic Name
Dose, Schedule, Special Instructions
is it renewable?
No
Yes
No
Yes
No
Yes
*Please ensure sufficient supply for the trip’s duration.
Special Needs
Do you have any special needs or require any specific support?
No
Yes
If yes, please specify:
Please bring any specific medical documentation (e.g. pathological findings in an electrocardiogram or x-ray)
that would be very helpful for a doctor in the host country to have, should you require treatment. Bringing it with
you can help avoid unnecessary and expensive procedures. It is recommended that you discuss this with your
regular physician.
CISV International Ltd
(Valid from 2015)
Page 2 of 5
Official Form
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