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)