Health Form DTS Health Form - Jun 2021 "*" indicates required fields First Name* First Last Name* Last Email* Gender* Female Male Date of Birth* Month Day Year Height* Weight (please specify lbs or kg)* Personal History: Please answer all questions. Please answer all questions. Have you ever had the following conditions or procedures? Explain any “Yes” answers in the space provided. Epilepsy* Yes No Please Explain: Fainting Spells* Yes No Please Explain: Mental Nervous Disorder* Yes No Please Explain: Asthma* Yes No Please Explain: Eating Disorder* Yes No Please Explain: Intestinal or Stomach Troubles* Yes No Please Explain: Recurrent Diarrhea* Yes No Please Explain: Anemia* Yes No Please Explain: Central Nervous Disorder (i.e. Multiple Sclerosis)* Yes No Please Explain: AllergiesFood* Yes No Please Explain: Medications* Yes No Please Explain: Please list and explain any other health issues, medical conditions, or physical disabilitiesAre you currently under a doctor's care for any condition?* Yes No Please Explain:* Are you taking medication at this time?* Yes No Please Explain:* Do you have a history of emotional instability or psychiatric treatment?* Yes No Please Explain:* Can you walk 3-4 miles per day?* Yes No Health InsuranceHealth Insurance Company Name Insurance Policy Number Emergency ContactName* First Last Relationship* Phone*Additional Phone NumberCOVID-19Will you be fully vaccinated against COVID-19 when you arrive?* Yes No Are you open to being vaccinated against COVID-19 if it gives you and your team more options for foreign outreach locations and types of ministry?** Yes No *This vaccination is not required but knowing this helps us in planning outreach locationsSignaturePlease type your full name to certify your agreement that the information provided is accurate and truthful* Today's Date* MM slash DD slash YYYY Δ
