RE: Youth Challenge International Medical Form. Dear Doctor:
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- Quentin Bond
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1 RE: Youth Challenge International Medical Form Dear Doctor: Thank you for helping to prepare this candidate for an overseas volunteer project with Youth Challenge International in a developing country. Your completion of the medical form is a critical piece of preparation and documentation needed by our volunteer participants. These projects can involve physically demanding work in humid, tropical conditions and are often far removed from dependable health care. These conditions require our participants to be physically fit and free of any illnesses that require regular or specialist medical attention. Please assess this applicant s physical fitness and medical history to ensure they are capable of fully participating in this type of project. Furthermore, an extended period away from family and friends in difficult circumstances does place emotional stress on our participants. Sadness and homesickness are common but occasionally some participants have real difficulties coping with the stress of project to the extent that they do not enjoy their time overseas. We ask that you investigate any previous coping difficulties that this applicant has had, including anxiety and depression, and assess their ability to overcome the mental challenges of project. Finally, during their extended stay in a developing community our participants may be exposed to health conditions not experienced by regular tourists to these countries. To protect our participants from disease, and to protect unvaccinated members of the community, we require our applicants to be fully immunized prior to travel. Please find our required vaccinations on the accompanying page. Unfortunately we are unable to accept participants unless these specified vaccination requirements are met. I sincerely thank you for your time in this matter and for the vital role you are playing in sending this individual on their overseas experience. If you have any questions about this form, or our medical requirements, please call our office at Best regards, David Danylewich Executive Director
2 YCI Medical Form PERSONAL DETAILS: Name: Sex: Date of Birth: Exam Date: How long have you known this person: PHYSICAL EXAMINATION: Please check to the right if normal: GENERAL HEALTH EYES E.N.T. DENTAL CONDITION LUNGS AND CHEST CARDIOVASCULAR SYSTEM ABDOMEN GASTROINTESTINAL G-U SYSTEM SKIN, LYMPHATICS MUSCULOSKELETAL SYSTEM NEUROLOGICAL SYSTEM Normal If Abnormal, please describe: Page 2 of 6
3 PHYSICAL HISTORY: (Please include major illnesses, hospitalization, injuries and surgical procedures which may affect health when living in a developing country) PRESENT MENTAL STATUS: a. Are you able to detect any disorders of affect? b. Does this person have trouble coping with stress? c. Does this person have trouble with anxiety? d. Does this person have trouble with depression? e. Does this person have any eating disorders? f. Does this person have any history of substance abuse? Yes No For each question marked yes, please explain fully in the space provided below or on an additional sheet. Page 3 of 6
4 MEDICATIONS: In the table below, please list any medications that the person is currently taking and provide details accordingly. Please ensure that all oralcontraceptives and over-the-counter medications are also listed here. Name of Medication (i.e. Ferrous sulfate) Dose (i.e. 300mg) Length of Course (i.e. 3x/day for 1 month starting June 1, 2006) Reason (i.e. for treatment of iron deficiency anemia) ALLERGIES: In the table below, please list and provide details regarding any known Medication (i.e. Penicillin), Environmental (i.e. latex, pollen), or Food (i.e. shellfish) allergies. Allergen (i.e. Penicillin) Reaction: Nature & Duration (i.e. Anaphylaxis, within two minutes of exposure) Treatment (i.e. Epi-pen, Benadryl) Page 4 of 6
5 DIETARY RESTRICTIONS: In the space below, please list and provide details regarding any special dietary restrictions this person might have: VACCINATIONS: Please also discuss the required vaccinations with the participant and review the vaccination list for suitability for their country destination. If possible have the participant secure the required vaccinations or establish a plan of action. PHYSICIAN S CERTIFICATION: This is to certify that I have examined and found her/him to be: Medically fit for an overseas posting as described in the cover letter Medically fit with limitation (please describe limitations) NOT medically fit for an overseas posting as described in the cover letter Physician s Signature and Stamp Printed name of physician Address of physician License # Date ( ) - ( ) - Phone number of physician Fax number of physician Page 5 of 6
6 MEDICAL INFORMATION RELEASE CONSENT FORM Dear Doctor, If I have any physical or mental health issues that may cause concern for a rigorous placement in a developing country, YCI may want to investigate a little further to ensure that this is the right placement for me at this time. YCI will only be able to determine the basic information from the form you have just filled out, but they may need a little more detail. The YCI Medical Consultant, a Registered Nurse, may be calling you to discuss those particular issues to learn more about them. I give you, or the other staff in the practice, permission to discuss my medical information and history with the YCI Medical Consultant or any other staff from Youth Challenge International. Name: Signature: Date: Instructions for Volunteers: Please fill out this page and give it to your doctor. This form gives your doctor permission to discuss your file with the YCI Medical Consultant, a Registered Nurse, or another YCI staff person. We may require this in order to be able to fully assess whether you are fit for an overseas placement. Page 6 of 6
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