Medical form

The purpose of the following Medical Form is to help the Center for International Education (CIE) staff to be of maximum assistance to you.

Mild physical and psychological disorders can become serious under the stress of life while studying in a foreign country. It is important that the staff be made aware of any medical or emotional problems, past or present, which may take affect in a study abroad situation.

The information provided in the form will remain confidential and will be shared only with the program staff or appropriate professionals and only if pertinent to your well-being.

Personal Information
Your Name Your Name First Last
Gender
Please indicate your status at LCC
Personal Email Address
Phone Number

*Used during your time at LCC
*Include country code
Contact person in an event of emergency
Name Name First Last
Phone

Include country code
Medical Insurance

Information on your international medical insurance
Name of your insurance provider
Insurance Contact in Emergency

Include country code
Insurance Policy Number / Comments
MEDICAL HISTORY

Please fill this in to the best of your knowledge
Known Allergies

Known Allergies Drug allergy Food allergy I am not allergic, as far as I am aware If you have any of the allergies please specify what you are allergic to and the severity of your allergy:
Do you have any dietary restrictions?

Do you have any dietary restrictions? Yes No If yes provide details: If yes provide details:

Have you been diagnosed with or suffer from any of the following?
	Yes	No
Diabetes	DiabetesYes	DiabetesNo
Asthma	AsthmaYes	AsthmaNo
Seizure Disorder	Seizure DisorderYes	Seizure DisorderNo
Muscular/Arthritic Disorder	Muscular/Arthritic DisorderYes	Muscular/Arthritic DisorderNo
Eating Disorder	Eating DisorderYes	Eating DisorderNo

Pregnancy Status (females only)
Have you in the past two years been treated by a psychiatrist, psychologist
or mental health professional for any mental, emotional or nervous disorder?

Have you in the past two years been treated by a psychiatrist, psychologist
or mental health professional for any mental, emotional or nervous disorder? Yes No If yes, indicate the dates of treatment:
Are you currently taking any medication?

Are you currently taking any medication? Yes No If yes, indicate the medications: If yes, indicate the medications:
Are there any predisposing medical or surgical conditions which may, under the stress of travel and relocating in a foreign country, cause problems during your study abroad program?
I certify that all the responses made on this Medical Information Form are true and accurate, and that I will notify the Center for International Education (CIE) Staff hereafter of any relevant changes in my health status.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Medical form

Medical form

Personal Information

Contact person in an event of emergency

Medical Insurance

MEDICAL HISTORY