HEALTH INFORMATION FORM

The personal information requested on this form is collected under the authority of Living & Learning International and will be used for the purpose of
administering aid related to physical, mental & emotional health. Living & Learning International will assist in the case of illness, injury, or other health-
related issue but will not assume responsibility as a health provider. Any questions regarding this form should be directed to the Living & Learning
International Health Coordinator.

IDENTIFICATION, INSURANCE & EMERGENCY CONTACT
Name (Last) (First) (Middle) Primary Address



Date of Birth Passport Number

/ /

Primary Health Insurance Carrier Policy Number



In Case of Emergency, notify:
(Name, Relationship & Phone Number)




MEDICAL HISTORY (check appropriate items)

o Acquired Immunodeficiency Syndrome (AIDS) or HIV Positive ! High Blood Pressure
o Arthritis ! Hypoglycemia
o Asthma ! Jaundice
o Bronchitis ! Kidney Disease
o Cancer ! Low Blood Pressure
o Chlamydia ! Mental Retardation
o Diabetes ! Pain or Pressure in Chest
o Dizziness ! Palpitations
o Emphysema ! Periods of Unconsciousness
o Epilepsy ! Rheumatic Fever
o Eye Problem(s) ! Rheumatism
o Fainting ! Seizures
o Frequent or Severe Headache/Migraine(s) ! Shortness of Breath
o Glaucoma ! Stomach, Liver or Intestinal Problem(s)
o Gonorrhea ! Syphilis
o Hearing Impairment ! Tuberculosis
o Heart Condition ! Tumor
o Hemodialysis ! Thyroid Problem(s)
o Herpes ! Urinary Tract Infection
o High Blood Cholesterol ! Other:


ALLERGIES & DRUG SENSITIVITIES

Allergy/Sensitivity Type (include medications, Reaction/Date Last Occurred/Treatment
foods, environmental, or other)









MEDICATIONS
Current prescription medications/over-the-counter Medications (taken on a regular basis)
(include date started & the quantity number/amount)










CURRENT INJURIES/RECENT SURGERIES (within the past year)