Personal Medical History Form
Applicant name
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First Name
Last Name
Date
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Month
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Day
Year
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General Health
Are you able to walk up to 3 miles (5 kilometers) in one day?
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Yes
No
Are you able to carry out reasonably strenuous physical work?
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Yes
No
Are you presently in good health?
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Yes
No
Please comment if you answered ‘no’ to any of the above questions:
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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.)
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Describe any current medical problems for which you are receiving treatment, or which may affect your health: (eg. Anaemia, diabetes, dental problems, hypertension, epilepsy, infectious diseases, etc.)
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List any serious illnesses in your family:
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List any medications which you currently take, either on a regular basis or when needed and why:
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List any allergies you have: (eg. Food, medication, latex, etc)
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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.)
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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)
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Describe any history or current problem with drug or alcohol abuse:
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Do you smoke/use tobacco?
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Yes
No
Occasionally
Is there any other health or medical information that will be helpful for us to know as we consider your application?
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*
I have read YWAM Ålesund’s privacy policy and agree to allow YWAM Ålesund to store and use my personal data.
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