Mission Trip Health Questionnaire

Name *
Date of Birth *
Date of Birth
Do you have or have you had any of the following diseases or problems:
Rheumatic Fever
Heart Trouble, Heart Attack, Angina
High Blood Pressure
Chest Pain
High Cholesterol
Lung or Breathing Problems
Hives or Eczema
Allergies (food, animal, medicine, pollen)
Fainting Spells
Liver Disease
Thyroid Problems
Arthritis or Autoimmune Disorder
Joint Replacement
Kidney Problems
Kidney or Other Organ Transplant
Tuberculosis TB
Anxiety or Depression
Chronic Fatigue
Are you pregnant or think you might be pregnant?
Do you have any other diseases, condition or problem you think we should know about?
Are you currently taking any of the following:
Anticoagulant (Blood Thinners)
High Blood Pressure Medicines
Cortisone (Steroids)
Anticonvulsants (Seizure Medication)
Insulin or any other medicines to control blood sugar
Thyroid Hormone
Digitalis or other medicines for heart trouble
Hormone Supplements
Sedatives or Antipsychotics
Any other regular medications
In the past two years have you:
Been admitted to a hospital?
Been in an accident?
Been under medical care for serious illness?
Been in psychiatric care?
Seen a counselor regularly?
Adopted a child?
Do you have any health problems or physical limitations that might hinder your work in a different climate, high altitude or adverse living conditions?