Sample Health Information Form

U.S.-[FOREIGN SITE] Research Experience for Undergraduates (REU)
Department of ABC
XYZ University
Confidential Health Information Form
Participant Name _______________________________________________________

Date of Birth ____________ (mm/dd/yy) Height __________ Weight __________

Health Insurance: All Program participants are required to carry health insurance that covers injury or illness while traveling outside of the United States. See Health Insurance and Consent-to-Treat Form for details.

Do you have or have you had any disease or condition requiring medication, regular physician’s care, surgery or other treatment? If yes, please list:
_______________________________________________________________________
_______________________________________________________________________

Do you take any medication(s) on a regular, on-going basis? If yes, please list:
_______________________________________________________________________
_______________________________________________________________________

Have you ever sought professional help for a psychiatric or emotional problem? If yes, please explain:
_______________________________________________________________________
_______________________________________________________________________

Do you have any of the following? If yes, please explain type and severity:
Medication Allergies NO YES _____________________________
Food Allergies NO YES _____________________________
Other Allergies NO YES _____________________________
Asthma NO YES Require epinephrine or hospital? ___________
Diabetes NO YES Require insulin? _______________________
Epilepsy NO YES Explain: _____________________________
Do you have any other health condition that may need to be considered? If yes, explain:
_______________________________________________________________________
I understand that submission of inaccurate and/or incomplete information about medical and psychiatric health history may result in dismissal from the program. £ Yes £ No

Participant’s Signature _______________________________________
Date _________________________

Physician’s Statement (to accompany participant’s health information form)
Participant’s Name ______________________________________________________
Participant’s Address ______________________________________________________

Attention Physician: Your patient is requesting a health evaluation to participate in a [LABORATORY/FIELD] research program in [FOREIGN SITE] this summer. The experience requires [LEVEL OF PHYSICAL ACTIVITY] and presents [DEGREE OF EMOTIONAL CHALLENGE]. Participants must be able to function relatively independently during the [LENGTH OF TIME] duration. Environmental and other conditions the participant may face include, but are not limited to, the following: [LIST].

I examined ______________________________________ on _______________, 200__.

Listed below are my patient’s abnormal findings:
______________________________________________________________________________

My patient is taking the following medication(s):
________________________________

Medication allergies: __________________________________________________________

Chronic medical conditions: ___________________________________________________

History of psychiatric or emotional problem(s)? £ NO £ YES
If yes, please explain:
______________________________________________________________________________

Immunization Record:	Primary Series Date(s) Booster Date(s)
DPT	________________	________________
Tetanus	________________	________________
MMR	________________	________________
Hepatitis A (suggested)	______________	________________
Hepatitis B (suggested)	________________	________________

In my judgment, the following physical or mental conditions are of potential concern for full and successful participation in the Program: ______________________________________________________________________________ In my opinion, __________________________ is £ or is NOT £ capable of participating in the described program.

Physician’s Signature: _______________________________________ Date ______________
Phsycian’s Name (please print) ___________________________________________________
Street Address ________________________________________________________________
City _______________________________ State _________ ZIP ___________
Phone _______________________________

Note: The XYZ University medical officer reviews these records. Copies are retained by the on-site coordinator in [FOREIGN SITE] for the duration of the Program.
Rev. 03/2002

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Last updated April, 2002 by Joan Marler