MARION MEDICAL MISSION 2009  HEALTH FORM

 

This form must be completed by BOTH you AND your physician.  After the physician has signed this form, please sign the lower portion certifying that you have had or will have the immunizations and medications listed and those required/recommended by the Center for Disease Control .  Then promptly return this form to Marion Medical Mission.  It may take a few months to complete immunizations—start immediately after acceptance for the mission trip.

 

                                                                PARTICIPANT/PATIENT NAME (Please print)

__________________________________________

 

This section must be completed by your Primary Care Provider. 

PRIMARY CARE PROVIDERS/CLINICIANS: IMPORTANT, PLEASE READ: Travel to Africa can be difficult, both physically and emotionally.   Please  know that travel will be long and tiring; vehicles will primarily be 4-wheel drive trucks on very rough roads, paths and many times off road.  Well sites are reached by walking, often long distances, sometimes uphill.  During that time of year, weather will be hot- mid-80's to 100 degrees, sometimes very humid, often breezy with dust and wood smoke in the air.  Health care resources are often a long distance away and inadequate.  Please be sure the patient is in good physical shape for this trip.


This trip will include travel to and from Africa, long hours of air and truck travel, visiting remote villages, sleeping in less than sanitary conditions, eating different foods, drinking only purified or boiled water, transportation on 4 wheel drive vehicles on very rough roads, strenuous exercise done in the African heat.

 

The Marion Medical Mission leadership team should be aware of the following medical or emotional conditions or physical limitations of this patient:

 

________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

 

This patient has the following allergies (include any medications to which this patient is allergic.)

 

_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________

 

List ALL MEDICATIONS this patient is taking (including dose and frequency of administration).

 

_______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

 

I have examined this patient and   (please check one)
______ found her/him in general good health and able to withstand the travels and lifestyle this trip will involve (as noted above).
______ do NOT recommend her/him for participation in this trip due to: ____________________________________________

 

Physicians Signature _______________________________________________________Date________________

 

Print/Type/Stamp Physician’s Name______________________________________________________________

 

Clinic Name (Please print)________________________________________________________________________

 

Clinic Office Mailing address______________________________________________________________________

 

City___________________________________________________  State__________  Zip Code ______________

 

Phone Number _________________________________________________________________________________

 

The following section must be completed by PARTICIPANT/PATIENT

 

I understand that the following immunizations and medications are recommended by the Center for Disease Control for the area and conditions of this project and are required by Marion Medical Mission.  I also understand that this original form must be returned to Marion Medical Mission.  By signing below, I certify that those immunizations and medications have either been completed or have been started and will be completed prior to September 18, 2009. 

____ TETANUS AND DIPHTHERIA,  ____ MALARIA TABLETS,  ____ TYPHOID,  ____ HEPATITIS A, ____ YELLOW FEVER, ____ POLIO,  ____ MENINGITIS,  ____ **PNEUMONIA, ____ ** INFLUENZA, ____ ***HEPATITIS B and I WILL DISCUSS/HAVE DISCUSSED TRAVELER’S DIARRHEA with my physician.  **Required for age 65 and above  *** Required for Health Care Workers.

 

Signature_______________________________________(Printed Name)________________________________Date________