FOR VOLUNTEERS ctiionet. This needs tobe completed by a physician, PA, Or nurse PS Volunteer Name and Date of Birth Fe 9106 Prose ar _ Taye Dear Medical Provider: font Please note that the patient may be located in a remote and isolated international area for 6 to 12 months where there is limited provision for medical treatment or renewal of prescriptions. The assignment could be physically ‘and emotionally demanding. Incorporate these considerations into your review. Please indicate if patient: 1. Has experienced a medical problem in the past ors currently undergoing treatment for heart attack, heart surgery, cancer, etc eS ie ——— 2. Has ever been treated or is currently receiving treatment for mental illness, nervous breakdown, depression, emotional or eating disorder, etc. Yes (No) ots seu tn 3. Has ever been treated ors currently receiving treatment for substance abuse (example: ilegal drugs, prescription medication, alcohol, etc.) a em : eet to tcc 5. Is currently receiving treatment for diabetes. Yes 6. Has a condition requiring immediate access to medical services or facilities. Yes ye ease tan. 7. Has allergies: environmental, medication or food. Yes (ye as sto. 8. Has asthma, Yes 9. Has a condition which limits physical activities. Yes (yes, oe ert),10. Has any Co ent in (crcl: Mid | Moderate / Sever) a eS oe 11. 1s currently tai E, an Prescription medication. (ityes, please explain) ca (lm pee) ______—— '2. Has any other reason why he/she should not be able to serve as a volunteer student missionary Yes (hee crtorpae ep) 13. Additional Comments: 14. Which of these vaccinations/immunizations does this volunteer have? (The volunteer is responsible fo ‘meet all requirements as indicated at http:/Awww.cde.qov)) tT lel ImmunizatonvVeccinaton _—_—Dala relevant) cov Fu if = v tev Mena Men wr A. ees Varela v Hepa v HepB / as other pails aR Medical Personnely io a — oe MON a0 Zz S HSUPSCCU 4327 DRVIROR OHOTMANCH a ee eS wos ol ae eae = ee ae Volunteer: f ng 1 Tilo FetanicivS agree to this form being shared wih relevant organizations who may consider my application