Ghana Health Form

Date *

Date

Full Name *

First Name Last Name

Traveler Email *

*NOTE: Please use the same email given at registration.

Phone Number *

Date of Birth *

Month Day Year

Age *

Gender *

Female Male

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Name *

First Name Last Name

Primary Emergency Contact Information *

First Name Last Name

Emergency Contact Relationship *

Emergency Contact Phone Number *

Please enter a valid phone number.

Secondary Emergency Contact Information *

First Name Last Name

Secondary Emergency Contact Relationship *

Secondary Emergency Contact Phone Number *

Please enter a valid phone number.

Medical Insurance Provider *

Company Name

Medical Insurance Policy Number *

Insurance Phone Number *

Please enter a valid phone number.

Subscriber *

I, {fullName}, do hereby authorize and permit MedSchoolCoach, LLC to bring me to the hospital or established clinic for evaluation and/or treatment. I understand that, if possible, the primary physician will be contacted so that he/she may participate in this treatment through various communication methods in the event of an emergency. In the event that the primary physician is not available, I hereby authorize the physicians and staff on duty at the hospital or clinic to treat me in the event of such an emergency (illness, accident or other injury). I understand that every reasonable effort will be made to contact the parent/guardian or designated emergency contact person in the event of such an emergency, but should these attempts fail, treatment may proceed. I further understand that in order for MedSchoolCoach, LLC to have the fullest opportunity to assist me, I must complete the contact information in this application. I realize and accept that all costs incurred as a result of this treatment may be billed directly to me if proper payment information is not included or insurance not approved for international care. By my signature below I release MedSchoolCoach, LLC, its entire staff and volunteers, the medical staff of the treating hospital or medical facility, local ambulatory services, clinical staff, nurses, drivers, and support personnel from any and all liability resulting from any action caused by such an emergency treatment. Signed on: {date}. *

Signature Clear

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Physician Information

Physician Name *

First Name Last Name

Physician Phone Number *

Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Medical History *

	Yes	No	If yes, explain
Diabetes
Hypertension (high blood pressure)
Adult or congenital heart disease/heart attack/chest pain (angina)/heart murmur/coronary artery disease. Any heart surgery or procedure.
Family history of heart disease or any sudden heart-related death of a family member before age 50.
Stroke/TIA
Asthma
Lung/respiratory disease
COPD
Ear/eyes/nose/sinus problems
Muscular/skeletal condition/muscle or bone issues
Head injury/concussion
Altitude sickness
Psychiatric/psychological or emotional disorders
Behavioral/neurological disorders
Blood disorders/sickle cell disease
Fainting spells and dizziness
Kidney disease
Seizures
Abdominal/stomach/digestive problems
Thyroid disease
Excessive fatigue
Obstructive sleep apnea/sleep disorders

List any other medical conditions, surgeries, or hospitalizations not covered above. *

Allergies *

	Yes	No	Explain?
Medication
Food
Plants
Insect bites/stings
Animal
Other

Immunizations *

	Yes	No	Date of Immunization
Tetanus
Pertussis
Diphtheria
Measles/mumps/rubella
Polio
Chicken Pox
Hepatitis A
Hepatitis B
Meningitis
Influenza
COVID-19
Other (i.e., HIB)

List all medications currently used, including over-the-counter medications

	Medication	Dose	Frequency	Reason
1.
2.
3.
4.
5.

I, {fullName} do hereby release MedSchoolCoach, LLC, its directors, and all subsidiary staff and volunteers from any and all liability resulting from the involvement of {fullName} in programs known as MedSchoolCoach or Ultimate Med Immersion . I understand clearly that staff, volunteers, and students may be interacting with, but not limited to, each other, the general public, patients, medical personnel, and medical students and/or exposed to, but not limited to, hospital rooms, operating rooms, morgues, and cadavers in a developing nation. I understand that although all necessary precautions will be provided through MedSchoolCoach, LLC, I agree to also take all necessary precautions for keeping safe and healthy. I have filled out all necessary forms required for attendance and have provided appropriate forms to our Primary Physician to be filled out and returned to MedSchoolCoach. Signed on: {date}. *

Signature Clear

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