Personal Medical History Form
Applicant name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
General Health
Are you able to walk up to 3 miles (5 kilometers) in one day?
*
Yes
No
Are you able to carry out reasonably strenuous physical work?
*
Yes
No
Are you presently in good health?
*
Yes
No
Please comment if you answered ‘no’ to any of the above questions:
*
Medical History
List all serious illnesses and operations you have had in the past. This means any illness requiring hospital admission, treatment from your doctor for an illness lasting more than a month, or any illness that may have an effect on your health. (Please also state the outcome and whether there are any residual problems.)
*
Describe any current medical problems for which you are receiving treatment, or which may affect your health (eg. anemia, diabetes, dental problems, hypertension, epilepsy, infectious diseases, etc.):
*
List any serious illnesses in your family:
*
List any medications which you currently take, either on a regular basis or when needed, and why:
*
List any allergies you have (eg. food, medication, latex, etc):
*
Do you follow a vegan or vegetarian diet? (Please be as specific as possible and be advised that you very likely need to assist to ensure your needs are met.)
*
Describe any current mental health issues for which you are receiving treatment or have received treatment in the past (eg. anxiety, depression, panic attacks, eating disorders, etc):
*
Describe any history or current problem with drug or alcohol abuse:
*
Do you smoke/use tobacco?
*
Yes
No
Occasionally
Is there any other health or medical information that will be helpful for us to know as we consider your application?
*
*
I have read YWAM Ålesund’s privacy policy and agree to allow YWAM Ålesund to store and use my personal data.
Privacy Policy
Submit
Should be Empty: