BLUE RIDGE COMMUNITY COLLEGE
WEYERS CAVE VA
STUDY ABROAD - CONFIDENTIAL MEDICAL HISTORY
The purpose of this form is to help Blue Ridge Community College be of maximum assistance to you should the need arise during your study abroad experience. Mild physical or psychological disorders can become serious under the stresses of life while studying abroad. It is important that the program be made aware of any medical or emotional problems, past or current, which might affect you in a foreign study context. The information provided will remain confidential and will be shared with program staff, faculty or appropriate professionals only if pertinent to your own well-being. Blue Ridger Community College may not be able to accommodate all individual needs or circumstances.
NAME _______________________________________________________________________
passport number ___________________________ PHONE (H) ________________ (W) ________________
ADDRESS ____________________________________________________________________
EMERGENCY CONTACT __________________________ RELATIONSHIP _____________
ADDRESS ____________________________________________________________________
PHONE (H) _______________________ (W) ______________________
HEALTH INSURANCE PROVIDER __________________________ POLICY# ___________
PHONE ______________________
(required) TRAVEL INSURANCE PROVIDER _____________________________ POLICY# ________________
AMOUNT OF COVERAGE _______________________________ MEDICAL EVACUATION ______
REPATRIATION ________
PHYSICIAN _________________________________________ PHONE ________________________
ALLERGIES _________________________________________________________________________
PHYSICAL DISABILITIES such as hearing difficulties,etc. _____________________________________________________________
HISTORY OF SERIOUS ILLNESS _______________________________________________________
HOSPITALIZATION REQUIRED? _______________________________________________________
CHRONIC ILLNESS ___________________________________________________________________
PLEASE LIST ANY ADDITIONAL INFORMATION THAT WOULD BE HELPFUL IN AN EMERGENCY
PROGRAM YOU ARE APPLYING FOR Blue Ridge Community College Spa 295 Immersion in Costa Rica, June 17-July 2, 2006
Medical Information: Have you ever been treated for, diagnosed by or consulted a physician, psychotherapist, counselor, or any other provider, or had indications of the following illnesses, injuries or conditions? Please check the appropriate box in the list below.
Yes No
’ Alcoholism or drug dependency/habit
’ Cancer
’ Diabetes ’ Treated with Insulin ’ Other
’ Disorder of the spine or discs
’ Epilepsy or seizures
’ Grand Mal ’ Petit mal ’ Other Date of last seizure (mm/yyyy) _______
’ Hypertension or high blood pressure
’ Hepatitis
’ Disorders of the stomach or intestines (including ulcers, colitis, or gastroesophageal reflux disease)
’ Kidney Disease or disorders
’ Depression
’ Bi-Polar Disorder
’ Multiple Sclerosis
’ Acquired Immunodeficiency Syndrome or Human Immunodeficiency Virus
In the space below, please list all the medications you are presently taking for ongoing medical conditions or for a chronic condition and the daily dosage.Remember to bring an adequate supply.
I certify that all responses made on this Medical Information Form are true and accurate, and I will notify Tidewater Community College hereafter any relevant changes in my health that occur prior to the start of the program.
SIGNATURE _______________________________________ DATE __________________