ICS Team Leader Personal Health Form

7/24/2019 ICS Team Leader Personal Health Form

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CONFIDENTIAL

PART 1: VOLUNTEER PERSONAL HEALTHFORM

(to be completed by the volunteer)

This form hs been desi!ned to help you" your doctor nd Interntionl #erviceidentify ny helth concerns tht my re$uire specil considertion" !iven tht youre intendin! to live nd %or& s volunteer overses'

lese complete ll sections of prt one of this form' our * %ill complete prtt%o' T&e your completed form to your medicl e+mintion'

Follo%in! your e+mintion" plese return the %hole form to Interntionl #ervices soon s possible' lese do notleve the form t your doctor,s sur!ery

Name:

Volunteer ref no:

Placement Country:

ate of !"rt#:

Occu$at"on:

Contact addre%% &"nclude $o%tcode':

Contact tele$#one num!er&%':

E(ma"l addre%%:

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)our current #ealt#

-' Do you hve ny si!ni.cnt helth problems t present/ es

No

If yes" plese specify0

1' Are you currently seein! your * re!ulrly for ny reson" or ttendin! hospitl

outptient" or on hospitl %itin! list/ es

No

If yes" plese !ive detils0

2' Are you currently receivin! ny dentl tretment/ es

No

lese !ive detils0

3' Are you t&in! ny re!ulr prescription mediction/ es

No

lese !ive detils0

4' Do you smo&etobcco/

es No

If so" ho% mny perdy/

5' Do you drin& lcohol/ es No

If so" ho% much per %ee&0

6ve you ever hd problem controllin! yourdrin&in!

hbits/ es

No

7' Are you ller!ic to0

Dru!s or medicines es8No Detils0 Food es8No Detils0 Insect bites or stin!s es8No Detils0

Do you crry drenlin8epipen to tret severe ller!ic rections/ es

No

9' Are you ve!n" ve!etrin or on specil diet/ es

No

lese !ive detils0

:' Is there history of ny of the follo%in! conditions in your fmily (prents orsiblin!s)/

hert disese stro&e dibetes epilepsy bleedin! or blood clottin!

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disorder

brest cncer depression8n+iety8psychosis lcohol or dru! dependency

other

If yes" plese !ive detils0

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Med"cal c#ec*l"%t &cont"nued on $a+e ,'

Ha-e you e-er %u.ered from any oft#e follo/"n+0 Plea%e +"-e furt#erdeta"l% "n t#e !o 2add"t"onal"nformat"on3 !elo/:

)e%4No

A$$rodate

"d you%ee your5P0)e%4No

"d you %ee a%$ec"al"%t0)e%4No

-;' 6i!h blood pressure

--' Fst or irre!ulr hert rhythm

-1' An!in

-2' 6ert ttc&

-3' undice or heptitis

12' *llstones

13' In?mmtory bo%el disese

14' @o%el sur!ery

15' idney disese or stones

17'


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Ha-e you e-er %u.ered from any oft#e follo/"n+0 Plea%e +"-e furt#erdeta"l% "n t#e !o 2add"t"onal"nformat"on3 !elo/:

)e%4NoA$$ro

date

"d you%ee your

5P0)e%4No

"d you %ee a%$ec"al"%t0

)e%4No

32' @c&che or slipped disc

33'


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date 5P0)e%4No

)e%4No

5;' 6evy" pinful" irre!ulr periods/

5-' Any problems durin! pre!nncy

51' @rest lumps" cysts" pin

52' Benopuse problems

53' Abnorml smer tests

54' Current contrceptive use (if ny)Add"t"onal "nformat"on &for /omen only %ect"on':

Tra-el #"%tory &to !e an%/ered !y all -olunteer%'

;f you #a-e tra-elled out%"de of Euro$e and Nort# Amer"ca "n t#e la%t 16year%< $lea%e +"-e !r"ef deta"l% "n %$ace !elo/ &e+: U+anda t/o mt#%7667'8 If you re$uire more spce plese use n dditionl sheet

Country: ate%: Healt# $ro!lem% dur"n+%tay:

Summary: ;% t#ere any ot#er med"cal "nformat"on you /ould l"*e to +"-e/#"c# you #a-e not "ncluded already0

..

..

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Plea%e document any $art"cular concern% you may #a-e related to your#ealt# /#"le a -olunteer o-er%ea%8 Plea%e d"%cu%% t#e%e /"t# t#edoctor dur"n+ your med"cal eam"nat"on< or contact ;nternat"onalSer-"ce8

..

..

..

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eclarat"on

lese red these sttements crefully before si!nin!0

I hereby declre tht ll the fore!oin! ns%ers re true nd" to the best of my

&no%led!e" I hve not %ithheld ny informtion' I understnd tht filure to

disclose ny e+istin! or previous medicl condition my invlidte my mediclinsurnce %hilst overses'

I !ive permission for the contents of this form to be for%rded to Interntionl

#ervice,s current insurers if this is necessry for my insurnce cover' I !ive permission for the Interntionl #ervice () Bedicl Adviser to contct my

doctor for further medicl informtion should this be re$uired'

S"+ned: ate:

CONFIDENTIAL

PART 7: VOLUNTEER PERSONAL HEALTHFORM

(to be completed by the e+minin! doctor)

Pat"ent=% %urname 5"-en name% Se A+e ate of eam"nat"on

o you #old t#e med"cal record% fort#"% $er%on0

;f ye%< /#at year do your record% +o!ac* to0

Ho/ many t"me% #a-e you %een t#"%$er%on "n t#e $a%t year0

S"+n">cant fam"ly #"%tory:

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Pa%t med"cal #"%tory &$lea%e +"-e deta"l% of any ma?or "llne%%e%

ICS Team Leader Personal Health Form

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