Medical Form 2010

Medical History:  Year 2010

Purpose of Medical Form:
This form protects you and MPP in that it alerts those persons who may not be medically fit for the strenuous work and difficult living conditions on the dig to reconsider their application. The form also helps our camp medical staff in case of problems during the project. Many people are not aware of how ailments, which are minor in a western urban setting, may become significant problems in an isolated area under stressful conditions. Therefore, we ask you, for your own protection, as well as for our assessment, to be completely candid in filling out and submitting this form and not to leave out anything that may be pertinent, even if you think it may jeopardize your application.

In addition to completing this form, check guidelines regarding vaccinations under "Health Notes" and other helpful health tips on the Information page.

All fields are required except the text boxes when a "NO" response is provided.  DEADLINE - 15 MAY 2010

Last Name: First Name:
Email:    
Birth Date: Occupation:
 
Name of medical/accident insurance plan:
Type of coverage: Policy #:
 
Address of company:
Street: City:
State or Province: Postal Code

Have you had any of the following? No / Yes Give details as to date, severity, any current problems or treatment.
Frequent eye infections
Glaucoma
Persistent ear infection
Loss of hearing
Diabetes
Typhoid Fever
Tuberculosis
Polio (with deformity)
Pneumonia or Pleurisy
Cancer or malignancy

Have you had any of the following? No / Yes Give details as to date, severity, any current problems or treatment.
Asthma or wheezing
Severe skin disease
Goiter or thyroid
Collapsed lung
Chronic cough
Shortness of breath (daily activities)
Palpitations of the heart or arrhythmias
Persistent heart murmur
Pressure around the heart
High blood pressure

Have you had any of the following? No / Yes Give details as to date, severity, any current problems or treatment.
Dysentery (bacterial, amoebic, parasitic)
Recurrent diarrhea or colitis
Yellow jaundice or Hepatitis
Stomach or duodenal ulcer
Gastritis or recurrent heartburn
Kidney or bladder infections
Varicose veins
Kidney Stones
Back injury or strain
Recurrent back pain

Have you had any of the following? No / Yes Give details as to date, severity, any current problems or treatment.
Painful joints (bursitis, arthritis)
Serious head injury
Hernia (rupture)
Fainting spells, dizziness, unconsciousness
Epilepsy, convulsive seizures
Migraine or other headaches, (except occasional tension headaches)
Nervous, emotional troubles
Anemia (low blood count)
If you have consulted a physician for any reason in the past 18 months (even for colds, flu, etc.), please give dates, reason and result.
If you have ever been hospitalized for a major physical or mental illness, surgery or injury, please give year, reason and result.

Question No / Yes Details
Do you now or have you ever had any allergies or any allergic reactions to drugs, injections, or insect bites?
Are you now taking (or have you taken within the last year) any medication or medical treatments, physiotherapy, etc.?
Have you been in the past year or are you currently restricted by a physician in any physical activities?
Have you been in recent contact with any serious infectious diseases (tuberculosis, hepatitis, etc.) i.e. family, immediate friends or co-workers?

Question No / Yes
Do you wear glasses?
If so, will you need to wear them while you dig?
Do you wear contact lenses?
If yes,will you wear glasses while excavating?
Are you color blind?
Have you had a tetanus booster within the last three years?
Date of booster shot: THIS IS A MUST!

If all the information you have provided is correct to the best of your knowledge please check here: your initials and today's date