Health History

Health History Form

Please complete this form at least 4 weeks before your program starts.

( * required items)

Participant Name: *

Email: *

Because traveling overseas can be both physically and emotionally demanding, we ask that you provide an honest evaluation of your health. A certain amount of stress due to culture shock or the change in living conditions and facilities is a normal part of the experience.However, in some cases, such stress may aggravate disabilities or an illness to which you have control of at home.

With this form, we hope to create an awareness of health issues that you should take into consideration before going abroad.This information will be used primarily to guide us in making appropriate arrangements for you as a Intrax Global Internships participant and will be forwarded to our in-country directors. Any information you provide will be kept confidential.

By submitting this form participant agrees that any and all health information may be released to on-site health care providers and host family/community organizations if deemed necessary to ensure the wellbeing of the participant

Health Notes (Please Be Thorough and Explain All Issues)

Operations/Serious Injuries (w/ dates):

Mobility or Physical Impairment Issues: 

Chronic/Recurring Illness or Conditions:

Mental Health Issues:

Dietary Restrictions (food allergies, vegatarian, vegan, etc):

Current Medications:

Additional notes or concerns:

Health Issues (Check all that apply)

Frequent Ear Infections:

Heart Defect/Disease:

Convulsions:

Diabetes:

Bleeding/Clotting Disorders:

Hypertension:

Mononucleosis:

Chicken Pox:

Measles:

German Measles:

Mumps:

Hay Fever:

Asthma:

Poison Ivy, etc:

Insect Stings:

Allergies of any type, including drug allergies:

Other:

Please explain any box checked above and give dates if applicable:

By checking the box on the right I verify that I have disclosed all necessary health information and that all information above is true and accurate to the best of my knowledge. I understand that failure to fully disclose any health conditions may result in my removal from the Intrax Global Internships programs.

*


Thank you!