Sample Health Information Form
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3Sample Health Information Form
U.S.-[FOREIGN SITE] Research Experience for Undergraduates (REU)
Department of ABC
XYZ University
Confidential Health Information Form
Participant’s Name
____________________________________________________
Date of Birth ____________ (mm/dd/yy) Height __________ Weight__________
Health Insurance:
All Program participants are required to carry health insurance that
covers injury or illness while traveling outside of the United States.
See Health Insurance and Consent-to-Treat Form for details.
Do you have or have you had any disease or condition requiring medication, regular
physician’s care, surgery or other treatment? If yes, please list:
_______________________________________________________________________
_______________________________________________________________________
Do you take any medication(s) on a regular, on-going basis? If yes, please list:
_______________________________________________________________________
_______________________________________________________________________
Have you ever sought professional help for a psychiatric or emotional problem? If yes,
please explain:
_______________________________________________________________________
_______________________________________________________________________
Do you have any of the following? If yes, please explain type and severity:
Medication Allergies
NO
YES
_____________________________
Food Allergies
NO
YES
_____________________________
Other Allergies
NO
YES
_____________________________
Asthma
NO
YES
Require epinephrine or hospital?
___________
Diabetes
NO
YES
Require insulin?
_______________________
Epilepsy
NO
YES
Explain:
_____________________________
Do you have any other health condition that may need to be considered? If yes, explain:
_______________________________________________________________________
I understand that submission of inaccurate and/or incomplete information about medical
and psychiatric health history may result in dismissal from the program. ! Yes ! No
Participant’s Signature
_______________________________________
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