Medical Form 2016

Medical History: Year 2016

Purpose of Medical Form:
This form protects you and MPP in that it alerts those persons who may not be medically fit for the strenuous work and difficult living conditions on the dig to reconsider their application. The form also helps our camp medical staff in case of problems during the project. Many people are not aware of how ailments, which are minor in a western urban setting, may become significant problems in an isolated area under stressful conditions. Therefore, we ask you, for your own protection, as well as for our assessment, to be completely candid in filling out and submitting this form and not to leave out anything that may be pertinent, even if you think it may jeopardize your application.

In addition to completing this form, check guidelines regarding vaccinations under "Health Notes" and other helpful health tips on the Information page.

All fields are required except the text boxes when a "NO" response is provided. DEADLINE - 15 MAY 2016

Information:

Last Name

First Name

Email Address

Birth Date

Occupation

Medical Information:

Name of medical/accident insurance plan

Type of coverage

Policy Number

Address of company:

Street

City

State or Province

Postal Code

Have you had any of the following?	Give details as to date, severity, any current problems or treatment.
Frequent eye infections	No Yes
Glaucoma	No Yes
Persistent ear infection	No Yes
Loss of hearing	No Yes
Diabetes	No Yes
Typhoid Fever	No Yes
Tuberculosis	No Yes
Polio (with deformity)	No Yes
Pneumonia or Pleurisy	No Yes
Cancer or malignancy	No Yes

Have you had any of the following?	Give details as to date, severity, any current problems or treatment.
Asthma or wheezing	No Yes
Severe skin disease	No Yes
Goiter or thyroid	No Yes
Collapsed lung	No Yes
Chronic cough	No Yes
Shortness of breath (daily activities)	No Yes
Palpitations of the heart or arrhythmias	No Yes
Persistent heart murmur	No Yes
Pressure around the heart	No Yes
High blood pressure	No Yes

Have you had any of the following?	Give details as to date, severity, any current problems or treatment.
Dysentery (bacterial, amoebic, parasitic)	No Yes
Recurrent diarrhea or colitis	No Yes
Yellow jaundice or Hepatitis	No Yes
Stomach or duodenal ulcer	No Yes
Gastritis or recurrent heartburn	No Yes
Kidney or bladder infections	No Yes
Varicose veins	No Yes
Kidney Stones	No Yes
Back injury or strain	No Yes
Recurrent back pain	No Yes

Have you had any of the following?	Give details as to date, severity, any current problems or treatment.
Painful joints (bursitis, arthritis)	No Yes
Serious head injury	No Yes
Hernia (rupture)	No Yes
Fainting spells, dizziness, unconsciousness	No Yes
Epilepsy, convulsive seizures	No Yes
Migraine or other headaches, (except occasional tension headaches)	No Yes
Nervous, emotional troubles	No Yes
Anemia (low blood count)	No Yes
If you have consulted a physician for any reason in the past 18 months (even for colds, flu, etc.), please give dates, reason and result.
If you have ever been hospitalized for a major physical or mental illness, surgery or injury, please give year, reason and result.

Question	Details
Do you now or have you ever had any allergies or any allergic reactions to drugs, injections, or insect bites?	No Yes
Are you now taking (or have you taken within the last year) any medication or medical treatments, physiotherapy, etc.?	No Yes
Have you been in the past year or are you currently restricted by a physician in any physical activities?	No Yes
Have you been in recent contact with any serious infectious diseases (tuberculosis, hepatitis, etc.) i.e. family, immediate friends or co-workers?	No Yes

Question
Do you wear glasses?	No Yes
If so, will you need to wear them while you dig?	No Yes
Do you wear contact lenses?	No Yes
If yes,will you wear glasses while excavating?	No Yes
Are you color blind?	No Yes
Have you had a tetanus booster within the last three years?	No Yes

Booster Shot:

Date of booster shot

If all the information you have provided is correct to the best of your knowledge please check here