Confidenal Medical Form - ywamdp.org · This Confidenal Medical Form has two ......
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Name of Applicant School IMPORTANT: This Confiden7al Medical Form has two parts: Part A is to be completed by the applicant and reviewed by a Physician, Physician's Assistant or Nurse Prac77oner Part B is to be completed by a Physician , Physician's Assistant or Nurse Prac77oner Are you presently under a doctor's or counselor's care for any condi3on? Yes No Specify Do you have any physical challenges that could hinder your experience with YWAM DP? Yes No Specify Do you have any allergies? (i.e. food, medicines, bee s3ngs, etc) Yes No Specify Do you have any medical doctor diagnosed food alergies such as Ciliac or lactose intolarence?) Yes No Specify Do you use (or have you used) tobacco products of any kind? Yes No Specify What is your opinion of the use of Marijuana or other illegal drugs? Are you presently taking medica3ons of any kind? Yes No Specify Confiden7al Medical Form Month/YYYY The applicant named above has applied for admission to a University of the Na7ons accredited program at a YWAM Des7na7on Paradise base. YWAM (Youth With A Mission) is an interna7onal, interdenomina7onal Chris7an missionary organiza7on. Founded in 1960, YWAM now has centers in over 1000 loca7ons in over 135 countries around the world. YWAM's purposes include training, challenging Chris7ans to fulfill the command of Jesus to "Go therefore and make disciples of all na7ons..." having the desire to "know God and make Him known". For more informa7on about YWAM and YWAM Des7na7on Paradise, please visit our web site www.des7na7onparadise.org. Part A ‐ to be completed by the applicant and reviewed by a Physician, Physician's Assistant or Nurse Prac77oner
Transcript of Confidenal Medical Form - ywamdp.org · This Confidenal Medical Form has two ......
NameofApplicant School
IMPORTANT:ThisConfiden7alMedicalFormhastwoparts:PartAistobecompletedbytheapplicantandreviewedbyaPhysician,Physician'sAssistantorNursePrac77onerPartBistobecompletedbyaPhysician,Physician'sAssistantorNursePrac77oner
Areyoupresentlyunderadoctor'sorcounselor'scareforanycondi3on? Yes NoSpecify
DoyouhaveanyphysicalchallengesthatcouldhinderyourexperiencewithYWAMDP? Yes NoSpecify
Doyouhaveanyallergies?(i.e.food,medicines,bees3ngs,etc) Yes NoSpecify
Doyouhaveany medical doctor diagnosed food alergies such as Ciliac or lactose intolarence?) Yes NoSpecify
Doyouuse(orhaveyouused)tobaccoproductsofanykind? Yes NoSpecify
WhatisyouropinionoftheuseofMarijuanaorotherillegaldrugs?
Areyoupresentlytakingmedica3onsofanykind? Yes NoSpecify
Confiden7alMedicalForm
Month/YYYY
TheapplicantnamedabovehasappliedforadmissiontoaUniversityoftheNa7onsaccreditedprogramataYWAMDes7na7onParadisebase.YWAM(YouthWithAMission)isaninterna7onal,interdenomina7onalChris7anmissionaryorganiza7on.Foundedin1960,YWAMnowhascentersinover1000loca7onsinover135countriesaroundtheworld.YWAM'spurposesincludetraining,challengingChris7anstofulfillthecommandofJesusto"Gothereforeandmakedisciplesofallna7ons..."havingthedesireto"knowGodandmakeHimknown".Formoreinforma7onaboutYWAMandYWAMDes7na7onParadise,pleasevisitourwebsitewww.des7na7onparadise.org.
PartA‐tobecompletedbytheapplicantandreviewedbyaPhysician,Physician'sAssistantorNursePrac77oner
NameofApplicant School
IMPORTANT:ThisConfiden7alMedicalFormhastwoparts:PartAistobecompletedbytheapplicantandreviewedbyaPhysician,Physician'sAssistantorNursePrac77onerPartBistobecompletedbyaPhysician,Physician'sAssistantorNursePrac77oner
Height Weight Overweight? Yes No
BloodPressure Pulse BloodType
SystemsSurvey(pleasecheckeachandcommentonanyirregulari7esorrecommenda7onsforfollowup)
E.N.T. Comments
Ophthalmological
Teeth
Neurological
Cardiovascular
Respiratory
Physician'sRecommenda9onsAcceptablewithoutlimita7ons Acceptablewithlimita7ons Notacceptable
Comments
Physician'sName(PleasePrint)
Address
Phone
Physician'sSignature Date
Musculoskeletal
Endocrine
Lymphatic
Dermatological
Psychiatric
Confiden7alMedicalForm
Month/YYYY
TheapplicantnamedabovehasappliedforadmissiontoaUniversityoftheNa7onsaccreditedprogramataYWAMDes7na7onParadisebase.YWAM(YouthWithAMission)isaninterna7onal,interdenomina7onalChris7anmissionaryorganiza7on.Foundedin1960,YWAMnowhascentersinover1000loca7onsinover135countriesaroundtheworld.YWAM'spurposesincludetraining,challengingChris7anstofulfillthecommandofJesusto"Gothereforeandmakedisciplesofallna7ons..."havingthedesireto"knowGodandmakeHimknown".Formoreinforma7onaboutYWAMandYWAMDes7na7onParadise,pleasevisitourwebsitewww.des7na7onparadise.org.
Hernial Orifices
Urological
PartB‐tobecompletedbyaPhysician,Physician'sAssistantorNursePrac77oner(pleasereviewPartA)
