Cisv International Programme Participant Health Information Form Page 5
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5Part E: PHYSICIAN’S DECLARATION CONCERNING CISV PARTICIPANT
TO THE PHYSICIAN: The participant will take part in a CISV International programme. Please consider the participant’s general physical
fitness and mental health in relation to the general requirements of programme participation as will be explained to you by the participant
or his/her parent/guardian. Please review the health information entered in Parts A, B and C and any other information you have available
to you regarding the participant’s medical history. This may include a physical examination if considered appropriate. Please discuss with
the participant any medical advice and vaccinations necessary for travel to the host country. The signing physician is responsible only for
information entered in Part E of this form.
I am
the participant’s primary care physician.
I am not
I have reviewed the information provided above and verify it is consistent with the information
False
True
available to me about the participant’s medical history:
I have no information on or knowledge of the participant’s medical history beyond what the
False
True
participant has shown me in the above sections of this form
Comments:
The participant appears to be physically and mentally fit for travel to and participation in the
No
Yes
CISV International programme:
No
Yes
Physical examination performed:
Additional comments/relevant examination findings:
No
Yes
Is there any apparent evidence of alcohol and/or drug abuse?
No
Yes
Is there any apparent evidence of infectious disorders or diseases?
This participant may take part in all activities with the following restrictions or
None
recommendations:
Details on limitation of participation (if any):
TRAVEL MEDICINE
No
Yes
The participant has received appropriate advice on travel health relevant to travel to the host nation:
No
Yes
The participant has received all recommended immunizations for travel to the host nation:
No
Yes
The participant is receiving malaria prophylaxis for travel to the host nation (if necessary):
I certify that all information entered on this page of this form is true and accurate to the best of my professional knowledge.
Signature of Examining Physician: ____________________________________________
Physician’s Stamp or Business Card
here:
Name of Examining Physician: _______________________________________________
Date: ____________________________________________________________________
CISV International Ltd
(Valid from 2015)
Page 5 of 5
Official Form
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