Sample Health Information Form (Page 3 of 3) in pdf

Physician’s Statement (to accompany participant’s health information form)

Participant’s Name

______________________________________________________

Participant’s Address ______________________________________________________

Attention Physician:

Your patient is requesting a health evaluation to participate in a

[LABORATORY/FIELD] research program in [FOREIGN SITE] this summer. The experience

requires [LEVEL OF PHYSICAL ACTIVITY] and presents [DEGREE OF EMOTIONAL

CHALLENGE].

Participants must be able to function relatively independently during the

[LENGTH OF TIME] duration. Environmental and other conditions the participant may face

include, but are not limited to, the following: [LIST].

I examined ______________________________________

on _______________, 200__.

Listed below are my patient’s abnormal findings:

______________________________________________________________________________

My patient is taking the following medication(s):

________________________________

Medication allergies:

__________________________________________________________

Chronic medical conditions:

___________________________________________________

History of psychiatric or emotional problem(s)?

YES

If yes, please explain:

______________________________________________________________________________

Immunization Record:

Primary Series Date(s)

Booster Date(s)

DPT

________________

Tetanus

________________

MMR

________________

Hepatitis A (suggested)

________________

Hepatitis B (suggested)

________________

In my judgment, the following physical or mental conditions are of potential concern for full and

successful participation in the Program:

______________________________________________________________________________

In my opinion, __________________________ is

or is NOT

capable of participating in the

described program.

Physician’s Signature: _______________________________________ Date ______________

Phsycian’s Name (please print) ___________________________________________________

Street Address ________________________________________________________________

City

_______________________________ State

_________

ZIP

___________

Phone _______________________________

Note: The XYZ University medical officer reviews these records. Copies are retained by the

on-site coordinator in [FOREIGN SITE] for the duration of the Program.

Rev. 03/2002

Sample Health Information Form Page 3

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