MEDICAL CLEARANCE FORM CHECKLIST
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1 Office of Study Abroad 720 Northern Blvd Brookville, NY (516) MEDICAL CLEARANCE FORM CHECKLIST Read all requirements and instructions carefully. MEDICAL HEALTH HISTORY (Completed by student) Read All Headings: a) Health Insurance b) Medical Information c) General Health Medical History: answer Y or N to all Mental Health History: answer Y or N to all Other Relevant Information: Provide necessary information Student Signature and Parent/Guardian Signature IF Under 18 HEALTH CLEARANCE (Completed by health care provider) Provider must mark one box (either CLEARED or NOT CLEARED) Provider s Signature, Name (please print), Title, Specialty, Phone Number & Date
2 Medical Health History Students with known and/ or ongoing medical conditions must prepare for and manage their condition overseas. Please read and complete all sections of this form. Health Insurance All students must have domestic health insurance coverage and purchase travel insurance to cover for foreign travel, medical evacuation, and repatriation. Students must show proof of coverage. Medical Information Please answer all questions completely. Timely disclosure of your health information will allow the University to support your overseas experience effectively. Mild physical or psychological disorders can become serious under the stresses of studying and traveling abroad. Therefore, it is important that you inform LIU staff of any medical or emotional conditions, past or current, which might affect your safety and welfare or that of other program participants. The information provided will be handled confidentially and will be shared with program staff and faculty only to the extent needed to secure health care or disability accommodations or if pertinent to your well-being in a housing placement or academic setting. General Health List any recent or continuing health problems: Surgeries (list type and year): List any physical or learning disabilities:
3 Drug/ Food Allergies (list and briefly describe reactions) : Blood Type: Medical History Have you ever suffered from, been treated for, or hospitalized for the following? Y N DATE Y N DATE Y N DATE HEADACHES ULCER/COLITIS BACK/JOINT PROBLEMS EPILEPSY HEPATITIS/GALLBLADDER HIGH BLOOD PRESSURE ASTHMA/LUNG DISEASE BLADDER/KIDNEY PROBLEMS THYROID PROBLEMS HEART DISEASE DIABETES RECURRENT OR CHRONIC ANEMIA OR BLEEDING CANCER/TUMORS INFECTIONS OTHER ANY MENTAL HEALTH CONDITION (SUCH AS DEPRESSION OR ANXIETY SUBSTANCE ABUSE (ALCOHOL OR DRUGS) EATING DISORDER (ANOREXIA/BULIMIA ARE YOU TAKING/HAVE YOU EVER TAKEN MEDICATION FOR THE ABOVE Mental Health History Y N DATE PLEASE PROVIDE AN EXPLANATION FOR ANY BOX YOU HAVE CHECKED
4 Are you currently under the care of a doctor or other health care professional, including mental health treatment? Yes No If yes, for what condition(s): Doctor s name: Phone: Other Relevant Information In order to provide the best access to health facilities abroad, please provide any other information relevant to your health, which may be necessary for LIU personnel to know during your travel: I acknowledge that domestic and travel health insurance is mandatory and that my health history is correct. I have no physical conditions that affect my ability to travel and/or participate in any of the activities involved in the LIU Study Abroad Programs. I understand that I am responsible for notifying the appropriate LIU administrator immediately of any injury, sickness or other medical condition or change to the medical information herein provided. Signature of Participant Date
5 Health Provider Instructions (Read carefully before signing form) Health provider must be licensed in the U.S. and cannot be an immediate family member. (AMA Code of Ethics E- 8.19) 1) LIU will not approve the student s participation in the program unless health clearance forms are satisfactorily completed and health practitioners certify that the student is medically stable. 2) The student must complete required information on the attached form. Blank forms, without the student s name, will be returned to the health practitioner. 3) You must consider the student s general fitness and physical and mental health in relation to the general requirements of program participation. Understand that students with disabilities or health-related needs who are requesting reasonable accommodation to meet the requirements of the program (as set in the program description), must submit documentation of the disability, along with their request and a copy of this form to Learning Support Services. LIU cannot guarantee that services are available, nor do we guarantee the accessibility of transportation vehicles, housing or hotel/ hostel accommodations, study sites or the environs to which students may travel. If a specialist or specialists is/ are currently seeing the student for an ongoing medical or mental health condition, each specialist also must approve and sign this health clearance form, and provide legible contact information or the form will be returned. Please note that the student must be cleared to participate in the program by the student s physician/ health practitioner and each specialist. Follow These Steps 1. The Student must present to you: (a) a completed confidential Medical Health History Form; and (b) a description of the program. Please review the confidential Medical Health History Form for accuracy. 2. Discuss/ review the student s health thoroughly, referring to: the confidential Medical Health History form, the student s medical records on file, and the general requirements of program participation; paying particular attention to medications and immunizations that the student may need, any allergies the student may have, and all currently active health problems. 3. Indicate on the Health Clearance Form if the student requires services to facilitate participation in the academic program so that LIU can assist the student in determining the availability of adequate services at the program site. 4. Pay special attention to any physical, emotional, or psychological conditions. LIU is concerned for the well-being of students with a history of health conditions that require medication and/ or continued therapy while abroad. Students may be cleared for participation if: in the opinion of the examining practitioner and specialist(s), and medical condition they may have is under control, they have a treatment plan in place for required ongoing care while abroad, and they have been stable on their medication for a reasonable period. 5. Indicate on the attached form that you have discussed with the student all health and medication management, and services that would be needed abroad. Students must take a sufficient amount of medication to last for the duration of their study abroad program and make sure that the prescription is available and legal in the host country. You may need to write a letter for the student to bring along with any medications, describing the medication and prescription.
6 Health Clearance Forms without signatures and required information will be considered incomplete and will be returned to you for completion. I have reviewed thoroughly the student s health, referring to the student s confidential Medical Health History form, medical records on file, and the attached program description. Based on the information contained in the student s medical records and provided to me by the student, both in person and on the confidential Medical Health History form, as well as my current observation of this student, to the best of my knowledge, the student is Student is cleared (Check all that apply) No medical or mental health contraindications to participation in the LIU Study Abroad program the student has chosen. Student requires services to facilitate participation in the academic program (e.g., note taking, wheelchair access). LIU cannot guarantee that services are available; student must submit documentation of their disability or health- related need, along with a request for a reasonable accommodation to Learning Support Services. Student requires a sufficient supply of medication to last through the duration of the LIU Study Abroad program the student has chosen and must ensure that the medication is available and legal. Student has a significant allergy to certain medication(s) and/ or certain food(s). Please list: Student is not cleared: There are medical or mental health contraindications to participation in the LIU Study Abroad program. Clearance is not warranted at this time. Health Care Provider/ Licensed Specialist Signature Health Care Provider/ Licensed Specialist Name, Title, and Specialty (Please Print) Phone number (include area code) Date
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PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
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