MEDICAL INFORMATION

*Must be completed by a Registered Physician in English

* Please note that disclosure of a physical or mental health condition does not automatically disqualify you from participation in Janus
International’s J-1 program. However, Janus International reserves the right to request additional documentation to verify your mental and
physical fitness for program participation. This form should be completed truthfully and honestly by a registered physician and signed by the
J-1 applicant at the bottom.

Patient’s Name:

Height: in cm Weight: in kg Blood Pressure: Pulse:

Please state the patient’s overall health:

Please check if the patient has been afflicted or is currently afflicted of the following:

Chicken Pox Seizure Measles Frequent Cough Mumps

Appendectomy Rheumatic Fever Diabetes Malaria Migraine
Hypertension Speech Defect Goiter Asthma Hepatitis

Anxiety/panic disorders Depression Other Physical or Mental Health Affliction (please explain below):

Has the patient been hospitalized within the past 5 years? Yes No

Is the patient currently taking injections or medications? Yes No

Does the patient have allergies? Yes No If yes, what is the patient allergic to and what reactions is

Has the patient been diagnosed with any illness or condition which requires regular medical attention? Yes No

Please provide detailed information about the patient’ s affliction:

the patient developing?:

Can these allergies be controlled by medications? Yes No

Is the patient able to work in a physically demanding job (including bending,pulling, pushing, lifting up to 50 lbs/23 kg)?

Yes No

Please state any restrictions of the patient during physical activities:

*Medical Insurance provided by Janus International Student Exchange does not cover pre-existing mental or physical medical conditions. The
participant has been made aware of any possible pre-existing conditions for which they may need additional fees for the insurance coverage.

Physicians Name: Place of Examination:

Signature : Date:

*I agree that the above information is a complete and total assessment of my health. I agree that I am physically and mentally
healthy enough to work at the assigned site of activity on my DS-2019 form.

Student Signature: Date: