MARION MEDICAL MISSION 2008  HEALTH FORM

 

This form must be completed by BOTH you AND your physician.  After the physician has signed this form, please sign the lower portion certifying that you have had or will have the immunizations and medications listed and those required/recommended by the Center for Disease Control .  Then promptly return this form to Marion Medical Mission.  It may take a few months to complete immunizations—start immediately after acceptance for the mission trip.

 

                                                                PARTICIPANT/PATIENT NAME (Please print)

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This section must be completed by your Primary Care Provider.  This trip will include travel to and from Africa, long hours of air and truck travel, visiting remote villages, sleeping in less than sanitary conditions, eating different foods, drinking only purified or boiled water, transportation on 4 wheel drive vehicles on very rough roads, strenuous exercise done in the African heat.

 

The Marion Medical Mission leadership team should be aware of the following medical or emotional conditions or physical limitations of this patient:

 

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This patient has the following allergies (include any medications to which this patient is allergic.)

 

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List ALL MEDICATIONS this patient is taking (including dose and frequency of administration).

 

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I have examined this patient and found her/him in general good health and able to withstand the travels and lifestyle this trip will involve (as noted above).

 

Physicians Signature _______________________________________________________Date________________

 

Print/Type/Stamp Physician’s Name______________________________________________________________

 

Clinic Name (Please print)________________________________________________________________________

 

Clinic Office Mailing address______________________________________________________________________

 

City___________________________________________________  State__________  Zip Code ______________

 

Phone Number _________________________________________________________________________________

 

The following section must be completed by PARTICIPANT/PATIENT

 

I understand that the following immunizations and medications are recommended by the Center for Disease Control for the area and conditions of this project and are required by Marion Medical Mission.  I also understand that this original form must be returned to Marion Medical Mission.  By signing below, I certify that those immunizations and medications have either been completed or have been started and will be completed prior to September 19, 2008. 

____ TETANUS AND DIPHTHERIA,  ____ MALARIA TABLETS,  ____ TYPHOID,  ____ HEPATITIS A, ____ YELLOW FEVER, ____ POLIO,  ____ MENINGITIS,  ____ **PNEUMONIA, ____ ** INFLUENZA, ____ ***HEPATITIS B and I WILL DISCUSS/HAVE DISCUSSED TRAVELER’S DIARRHEA with my physician.  **Required for age 65 and above  *** Required for Health Care Workers.

 

Signature_______________________________________(Printed Name)________________________________Date________