Report of Medical History

WEST COAST MISSIONS

Mail to: 670 Whiting Street, Grass Valley, CA 95945

(916) 202-5646  916-541-9526  life@westcoastmissions.com  steve@westcoastmissions.com

To the applicant: Please complete pages 1 and 2 before going to your physician for a physical exam. Then take all 4
pages with you to your physical. Your physician will complete page 3. Page 4 provides extra space for more details,
if needed. NOTE: This information is strictly for the use of the West Coast Missions program and will not be released
without your knowledge or consent.

APPLICANT'S INFORMATION
Name
Last Name First Name Middle Applicant's phone #

Address
Street Address City State Zip

Other Info Male Female

Citizenship Date of Birth

FAMILY HISTORY
Relationship Age State of Health
Father
Mother

Brothers

Sisters

Have any of your relatives ever had any of the following?

Type of illness Yes No Relationship Additional Comments
Heart Disease
Asthma, Hay Fever
Epilepsy, Convulsions
Cancer, Tumor, Cyst

APPLICANT'S MEDICAL HISTORY

Have you ever had any of the following? Please check yes or no for each condition.

Please explain about any of the above conditions for which you checked "yes". Use additional space on page 4 if necessary.

MEDICAL FORM
 West Coast Missions

APPLICANT'S MEDICAL HISTORY continued

Have you ever: If yes, please expalin in detail. Use page 4 if necessary.
Had seizures
Had fainting spells
Had an eating disorder
Had breathing problems
Had phychiatric counseling
Had chronic illness
Had cancer or a tumor
Had insomnia
Frequent anxiety/nervousness
Frequent anxiety/nervousness
Frequent Depression

Within the last two years have you ever: If yes, please explain in detail. Use page 4 if necessary.

Had psychiatric counseling

Been sexually active

Taken medication for an emotional disorder

Taken medication for depression

Had a significant gain or loss of weight
Had ADD or ADHD
Struggled with violence or anger
Had difficulty making new friends
Had any thoughts of suicide
Intentionally inflicted pain or injury
on yourself (cutting, etc)
If yes, please give the
reasoning behind your
Are you a vegetarian? If so, for how long? decision:

Please note that you may need to eat meat as a part of cultural sensitivity.

If yes, please give details (name, dosage, reason

Are you currently taking any prescription medication? for use):

Do you use any non-prescription drugs on a regulat basis? If yes, give details:

Do you have any physical impairments? If yes, give details:

I understand I am applying to be a missionary apprentice and will likely encounter difficult living conditions and
stressful situations. I have answered form completely truthful.

APPLICANT'S SIGNATURE Date:

MEDICAL FORM
 Report of Health Evaluation
To the examining physician: Please review the applicant's history of pages 1 and 2, then complete the information below.

BASIC HEALTH INFORMATION

Blood Pressure: / Height: Weight:

Corrected
Vision: Right 20/ Left 20/
HEALTH DETAILS:
Does the Applicant have abnormalities of: If yes, please fully describe. Use page 4 if necessary.
Head, ears, nose or throat
Respiratory
Cardiovascular
Gastrointestinal
Eyes
Musculoskeletal
Metabolic/Endocrine
Neuropsychiatric
Skin

Is there loss or seriously imparied function of any paired organs? If yes, please explain:

Does the applicant have any form of epilepsy? If yes, please explain:

Is that applicant diabetic? If yes, please explain:

Do you have any recommendations regarding care of this applicant? If yes, please explain:

Is the applicant now under treatment for any medical or emotional condition? If yes, please explain:

OVERALL ASSESSMENT
How would you rate the applicant's overall physical health condition?

How long have you been seeing the applicant as a patient in your practice? First visit 1-2 years
1-3 months 2-4 years
3-6 months 5+ years
6-12 months

PHYSICIAN'S INFORMATION
Physician's name (Please print) Physician's signature:

Physician's mailing address:

Street Address City State Zip

Date:

MEDICAL FORM
This space is provided for additional comments and explanations for items on pages 1-3.

MEDICAL FORM