Cisv International Programme Participant Health Information Form Page 3
Download a blank fillable Cisv International Programme Participant Health Information Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Cisv International Programme Participant Health Information Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5PART C: HEALTH HISTORY
In case of hospitalization by CISV, participant’s medical records are available from:
Physician / Hospital:
Telephone Number:
Address:
Has the participant ever had any infectious diseases? Please tick any that apply:
Measles (Rubeola)
Whooping cough (Pertussis)
Hepatitis (specify)
Frequent tonsillitis
Mumps
Scarlet fever (Scarlatina)
Encephalitis
Sinusitis
Rubella (German measles)
Rheumatic fever
Yellow fever
Bronchitis
Chickenpox (Varicella)
Otitis
Malaria
Pneumococcal infection
Staphylococcal infection
Streptococcal infection
Other, please specify:
Please provide a brief history/explanation regarding above and whether they have left any lasting complications:
Does the participant have any recurring medical problems or chronic conditions? Please tick any that apply:
Anemia/blood disorder
Eating disorder
HIV
Migraines/headaches
Asthma
Endocrine disorder
Kidney disease
Mobility limitations
Autism/Asperger’s
Diabetes
Learning disability
Musculoskeletal problems
Syndrome
Autoimmune disorder
Thyroid disease
Mental health concern
Neurological concerns
Cardiovascular disease
Eye disease*
Anxiety
Seizure disorder
Heart murmur
Gastrointestinal disease
Depression
Sleep disorder
Hypertension
Hearing problems
Psychotic illness
Tuberculosis
Attention deficit
Other, please specify:
hyperactivity disorder
(ADHD/ADD)
*If you wear glasses or contact lenses, please bring a copy of your prescription to the programme.
Please specify if there is anything that the programme
staff should be aware of relating to any of the above:
Is there any family history of the following? Please tick :
Allergies or asthma
Epilepsy
Hypertension
Migraines/headaches
Diabetes
Heart disease
Mental health problems
Skin diseases
Other, please specify:
Please specify if there is anything that the programme
staff should be aware of relating to any of the above:
CISV International Ltd
(Valid from 2015)
Page 3 of 5
Official Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical