National Volunteer Center

National Volunteer Center

English Opens Doors Program

General Health Information and Medical History

General Health Information and Medical History

Your Full Name *

Your Date of Birth *

Please select your Volunteer Service *

Please check the appropriate box(es) to indicate if you have (or had) the following medical conditions: *
AllergiesAsthma or hay feverSinus troubleFainting spellsCeliac diseaseChronic respiratory problemsChronic digestive/gastrointestinal problemsDiabetesEating disorderHead injuryHeart or circulatory complicationsHigh or low blood pressureIndigestion (frequent) or ulcerHepatitisLiver or gall bladder problemsMental health conditionMononucleosisNarcotic/alcohol dependencyParasitesProblems of the immune systemSeizures/epilepsySexually transmitted infection/sexually transmitted diseaseSkin diseaseStrokeThyroid or other endocrine problemsTuberculosisTyphoid FeverTonsillitisNo medical conditionsOther:

Please list dates and important information for any medical condition you indicated above.

Please explain which conditions should be taken into consideration for placement purposes:
For example, food/animal/environmental allergies, proximity to a hospital, etc.

In the past, I have:
Please check the box next to the appropriate question(s) if your answer is "yes".
Been hospitalized or had surgeryHad a significant medical condition not listed aboveHad a significant psychological or emotional condition not listed above

Please explain any boxes marked "yes" in the question above:

In an instance where an English Opens Doors Program staff member needs to assist you in an emergency, is there any information or relevant family history that a staff member should relay to medical professionals or emergency personnel on your behalf? *

Please type in your name below which will represent your signature stating that the information you provided in this form is accurate. *

Date on which you filled out the form: *