Health-History-Form

Health-History-Form - UC Davis Quarter Abroad 2010-2011...

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UC Davis Quarter Abroad 2010-2011 Health Screening Form Instructions NOTE: This form should ONLY be used by students with private health insurance (i.e. you submitted a SHIP waiver and receive medical care from a private physician) or who are non-UC Davis students. Completing the Health Screening process is a requirement for all students applying for a Quarter Abroad program. You must complete pages 1 – 3 before submitting your health screening form to your physician. For students seeing a Specialist / Psychotherapist for an ongoing condition, the Specialist/Psychotherapist must complete section one (1) on page 4 BEFORE review and final clearance is signed by the Physician or Health Practitioner. When making an appointment with your healthcare provider, be sure to explain that the purpose of this appointment is to prepare for and get clearance to study abroad. It is extremely important that you disclose all of your medical history to the medical professional who will be performing your clearance, even if you do not believe that your condition might create a problem for you while you are abroad. This allows medical professionals to help you make arrangements or plans necessary to ensure you get the most from your Quarter Abroad program. Students with known and ongoing medical problems, such as allergies or diabetes, must take special precautions in preparing for and managing their situations overseas. You need to anticipate how your new environment and the stresses of study abroad can impact your health. Preexisting emotional difficulties are often intensified by living in a foreign culture. There may be fewer resources in international settings to help a student deal with such problems. These issues do not preclude your participation but consultation with your doctor and careful planning are critical. INSTRUCTIONS FILL OUT pages 1 – 3 completely and honestly prior to meeting with your healthcare provider. If you have an ongoing condition, a Specialist/Psychotherapist must complete section one (1) on page 4 BEFORE review and final clearance is signed by the Physician or Health Practitioner. GET immunization records. If your healthcare provider does not already have your immunization records, you will need to bring these with you to your appointment. NOTE: Additional immunizations may be required for certain countries. Also be sure your routine vaccinations are up-to-date . TAKE pages 1 – 4 to your appointment with your healthcare provider. Your physician should review the Health Screening Form with you and complete and sign page 4 of the form. NOTE: If you are applying for a Quarter Abroad program in Argentina or Mexico , the Center for Disease Control (CDC) highly recommends that you get additional immunizations before you travel. Please visit the CDC travel website ( http://wwwn.cdc.gov/travel/default.aspx ) before your doctor’s appointment and review the list of Vaccine-Preventable Diseases
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Health-History-Form - UC Davis Quarter Abroad 2010-2011...

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