Amity Intern Program

Health Evaluation Form

PART 1: TO BE COMPLETED BY THE INTERN PROGRAM APPLICANT

Ousmane Ndom
NAME OF APPLICANT: ________________________________________________________

VACCINATION HISTORY: INDICATE THE VACCINES THAT YOU HAVE RECEIVED.

☐
☐* DIPHTHERIA/PERTUSSIS/TETANUS
☐
* MEASLES (RUBEOLA)

☐* MUMPS
☐
* POLIO
☐* CHICKENPOX/VARICELLA
☐
* HEPATITIS B

☐
* HEMOPHILUS B

☐
* BACILLUS CALMETTE-GUERIN (FOR TUBERCULOSIS)

* COVID-19
1. HAVE YOU RECENTLY BEEN TESTED FOR TUBERCULOSIS? ☐ YES ☐ NO
*
☐ POSITIVE* ☐ NEGATIVE
1A. IF YES, WHAT WAS THE RESULT OF THE TEST?
*
*IF TEST RESULT WAS POSITIVE, A CHEST X-RAY OR CLEARANCE LETTER IS REQUIRED.
1B. CHEST X-RAY RESULT: ☐ HAVE TB ☐ DO NOT HAVE TB DATE OF X-RAY: ____________

☐ YES ☐ NO
2. DO YOU HAVE ANY ALLERGIES?
* (IF YES, PLEASE LIST BELOW)

☐ YES ☐ NO
3. DO YOU HAVE ANY DIETARY RESTRICTIONS?
* (IF YES, PLEASE LIST BELOW)

☐ YES ☐ NO
4. ARE YOU CURRENTLY TAKING ANY PRESCIPTION MEDICATION?
*
(IF YES, STATE THE MEDICATION NAME AND THE CONDITION THAT YOU ARE BEING TREATED FOR BELOW)

☐ YES ☐ NO
5. HAVE YOU BEEN TREATED FOR ANY PSYCHOLOGICAL OR MENTAL DISORDERS?
(IF YES, PLEASE EXPLAIN WHY AND WHEN BELOW)
*
6. DO YOU HAVE ANY HEALTH PROBLEMS OR CONDITIONS THAT AMITY, YOUR HOST SCHOOL, OR YOUR HOST
☐ YES ☐ NO
FAMILY SHOULD BE AWARE OF?
* (IF YES, PLEASE EXPLAIN IN DETAIL BELOW)

BY SIGNING BELOW, I CERTIFY THAT THE INFORMATION UNDER PART 1 OF THIS FORM IS ACCURATE. I
UNDERSTAND THAT PROVIDING INCORRECT OR MISLEADING INFORMATION MAY RESULT IN CANCELLATION OF
MY INTERNSHIP. I AGREE TO MAKE THE NECESSARY ARRANGEMENTS FOR HEALTH INSURANCE COVERAGE THAT
MEETS THE J-1 VISA REQUIREMENTS. I UNDERSTAND THAT I WILL BE REQUIRED TO SUBMIT PROOF OF MY
INSURANCE COVERAGE TO AMITY INSTITUTE BEFORE ARRIVING IN THE U.S.

SIGNATURE OF INTERN PROGRAM APPLICANT: ______________________________ DATE: ______________

09/04/2023
(PHYSICAL SIGNATURE REQUIRED)

PART 2: TO BE COMPLETED BY THE APPLICANT’S TREATING PHYSICIAN

1. HAVE YOU EXAMINED THE APPLICANT? ☐ YES ☐ NO

*
☐ YES ☐ NO
2. IS PART 1 ABOVE ACCURATE TO THE BEST OF YOUR KNOWLEDGE?
*
3. HOW WOULD YOU RATE HIS/HER OVERALL PHYSICAL AND MENTAL HEALTH?

☐ EXCELLENT ☐ GOOD ☐ FAIR ☐ POOR

*
4. DO YOU CONSIDER THIS INDIVIDUAL TO BE PHYSICALLY AND MENTALLY ABLE TO PARTICIPATE IN A
TEACHING EXCHANGE PROGRAM IN THE U.S. FOR UP TO 10 MONTHS? ☐ YES ☐ NO
(IF NO, PLEASE EXPLAIN BELOW)
*
ADDITIONAL COMMENTS (OPTIONAL):

Physician Moustapha Dieng

NAME OF PHYSICIAN: _____________________________________________

Rufisque
ADDRESS: _______________________________________________________

+221 77 178 52 67
PHONE NUMBER: _________________________________________________

12/4/2023
SIGNATURE OF PHYSICIAN: __________________________________________ DATE: _______________
(PHYSICAL SIGNATURE REQUIRED)

OFFICIAL STAMP (IF APPLICABLE):

Amity Institute - 1775 Hancock Street, Suite 170 - San Diego, CA 92110 USA - www.amity.org