Personal Medical History Form

Applicant name *

First Name Last Name

Date *

Month Day Year

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: *

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. Anaemia, 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

Personal Medical History Form

General Health

Medical History