Bread of Life Internship Medical Form

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The mission of Bread of Life takes people to physically demanding areas of the world. Interns going overseas will face situations with little food or water, extremely hot weather, and lots of physical exercise. All interns will also participate in periods of fasting during the internship process.

In order for us to help ensure your ability to endure the physical rigors of the internship and for your overall well-being, we need you to complete the following health form. For those serving internationally, we need you to provide a recored of your immunizations and have a physical examination performed by your physician prior to entering the internship.

Additional immunizations and medication may be required at a later time, depending on the decided destination. Also, please scan a copy of your medical insurance/prescription card and send it to info@breadoflifeafrica.com. All medical information will be kept strictly confidential and will only be used by Bread of Life Missions Staff and any relevant insurance providers.

Email *

PERSONAL INFORMATION

I am applying to intern: *

overseas.

in the US.

Name: *

Date of Birth: *

YYYY

Gender: *

Male

Female

Present Address *

Phone: *

SSN: *

Blood Type: *

PAST MEDICAL HISTORY

List any serious medical illnesses/injuries you have or have had. *

List any operations you have had. *

List any allergies you have. *

MEDICATIONS

List medications taken regularly. *

Are you allergic or sensitive to any medicines? If so, please list. *

IMMUNIZATIONS

Please give the date of most recent immunization for that disease. Leave blank if you do not have the immunization yet.

Tetanus

YYYY

Polio

YYYY

Measles/Mumps/Rubella

YYYY

Pneumovax

YYYY

Influenza

YYYY

Hepatitis A

YYYY

Hepatitis B

YYYY

Yellow Fever

YYYY

Typhoid

YYYY

Meningococcal

YYYY

COVID-19

YYYY

FAMILY HISTORY

Please indicate which conditions are found in your family and explain if present.

High Blood Pressure *

Heart Disease *

Diabetes *

Cancer *

Kidney Failure *

Mental Illness *

Alcoholism *

Tuberculosis *

Rate your current health: *

Excellent

Poor

Describe your overal physical condition. *

Are there any other illnesses in your family? *

I certify that the information provided is true, correct, and complete to the best of my knowledge, information, and belief. (Please e-sign and date.) *

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