Medical Questionnaire

Study Abroad

Medical Questionnaire

(Step 1 of 3) Personal Agreement

Basic Information

INSTRUCTIONS TO PROGRAM PARTICIPANT:
Thank you for your time completing this medical questionnaire. It is extremely important that all participants be able to adjust to dramatic changes in climate, diet, and living conditions while traveling on a Moody Sponsored program. Traveling can also create emotional and physical stress for participants; in some cases, mild disorders can become serious under the stress of life in unfamiliar surroundings. A participant will not be removed from a program due to either a physical or emotional condition unless it is of such a serious nature that the participant becomes a danger to himself/herself or a danger to others. Please fill out this form accurately and completely.

This form must be completed at least 8 weeks prior to departure. ALL INFORMATION PROVIDED ON THIS MEDICAL REPORT IS CONFIDENTIAL AND WILL NOT BE RELEASED EXCEPT AS AUTHORIZED BY THE PARTICIPANT, BELOW.

Full Name *

Date of Birth *

Student ID Number *

Sponsoring Department *

Program Name *

Dates of Program *

Release to be Signed by the Participant

I hereby authorize and consent to the release of information in this Medical Questionnaire to my program's sponsoring department at Moody Bible Institute, Moody's Health Service and to the coordinator(s)/trip leaders of my program. This includes any information about my health status on a need-to-know basis to safeguard my health, safety, and welfare as well as that of the program participants during my program domestically or abroad.

Digital Signature *

Today's Date *

(Step 2 of 3) Medical Questions

Please Note

• Moody Bible Institute highly recommends that each participant receives a medical evaluation & recommendation from their healthcare provider before travelling domestically or abroad.

• Moody Bible Institute highly recommends that students take medical advice from their healthcare provider about the side effects that flying, temperature changes, jetlag & different foods may have on their reaction to medical conditions & medications.

• Participants are required to obtain recommended vaccinations from their healthcare provider before participation in international programming.
o Vaccination Recommendations according to the CDC:
 https://wwwnc.cdc.gov/travel/destinations/list

• Participants are responsible to reach out to the Student Resource Center to document any disability that requires a special “accommodation” or special conditions. He/she should request information about the Moody Sponsored International program in advance. The Student Resources Center will work with the sponsoring department & program leaders to make reasonable attempts to accommodate participants’ need while traveling domestically or abroad.

• If a student does not submit a medical questionnaire prior to departure, he/she will not be permitted to participate in the program.

Do you have any pre-existing medical conditions/requirements? Please list them below:

Are you, or have been treated for an ongoing medical (mental, physical, or learning related) condition in the past 3 years?

Please list any medication you are currently taking, and the medical condition treated:

Are you currently suffering from any mental health condition (e.g., anxiety disorder, depression, mood disorder, eating disorder, personality disorder, post-traumatic stress disorder, psychotic disorder etc.)? Have you been prescribed any medication for this mental health condition? If yes, what is the medication and are you taking the medication?

Do you have any allergies to medication(s)? If yes, please list and describe reaction.

Do you have any dietary requirements or severe allergies? If yes, please list and describe reaction.

Do you have any learning or physical disabilities that are documented with the Student Resource Center (SRC)? Participants are required to report any accommodations you may need while participating in the program to the Student Resource Center (SRC). PLEASE NOTE: Working with the Student Resource Center, the sponsoring department & program leaders will make reasonable attempts to accommodate students’ needs while travelling.

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