Personal Health History of Missionary Candidate

Renato G. Gerong
Brgy Tampoong
Sogod, Sogod
6606 Southern Leyte
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender
Kevin Carl Vasquez Reviso 0010080345211 26 Aug 2003 (19) Male
Please answer all of the following questions. Be honest with yourself, your physician, and the Lord. Major difficulties may result if this
information is not complete and accurate. Please do not withhold or deny any medical information.
Key: Current = is currently occurring; Previous = occurred previously, but is now resolved; Never = has never occurred

Current Previous Never 1. Persisting difficulties from serious injury or deformity of your head or repeated concussions

Current Previous Never 2. Sight impairment, glaucoma, or cataracts (need for glasses or contacts; chronic eye infection)

Current Previous Never 3. Problems with hearing normal conversation (require a hearing aid)

Current Previous Never 4. Recurrent sinusitis, sore throat, ear infections, or nasal obstruction

Current Previous Never Lung disease, emphysema, tuberculosis, shortness of breath, spitting or coughing up blood or colored
5.
sputum, or collapsed lung
Current Previous Never 6. Hay fever or allergies

Current Previous Never 7. Cystic Fibrosis

Current Previous Never 8. Asthma

Current Previous Never High blood pressure, irregular heart rhythm, congenital heart disease, coronary artery disease,
9.
cardiomyopathy
Current Previous Never 10. Varicose veins or thrombophlebitis

Current Previous Never Crohn’s disease, ulcerative colitis, heartburn, reflux, ulcers, irritable bowel, chronic diarrhea, rectal
11.
bleeding, celiac disease, gluten intolerance, or other gastrointestinal disorders
Current Previous Never 12. Gall bladder disease or stones, hepatitis, or cirrhosis or other liver problems

Current Previous Never 13. Rupture (hernia) or varicocele

Current Previous Never 14. Diabetes type 1 (insulin deficiency)

Current Previous Never 15. Diabetes type 2 (insulin resistance)

Current Previous Never 16. Organ Transplantation

Current Previous Never 17. Hypoglycemic attacks

Current Previous Never 18. Thyroid or other hormonal problems or unexplained weight loss

19. Kidney or urinary difficulties

Current Previous Never 19.1 Kidney disease or failure

Current Previous Never 19.2 Kidney stones

Current Previous Never 19.3 Enuresis (bed wetting)

Current Previous Never 20. Sexually transmitted disease

Current Previous Never 21. Skin condition, such as eczema or psoriasis

Current Previous Never 22. Acne requiring treatment

Current Previous Never 23. Sensitivity to the sun

Current Previous Never 24. Tattoos

Current Previous Never Back or neck injury, arthritis in back or neck, spondylitis, chronic back or neck pain, or difficulty lifting
25.
things
Current Previous Never Loss of any part, deformity, paralysis, joint pain, arthritis, or other problem in shoulder, elbow, hand,
26.
wrist, or other upper extremity.
Current Previous Never Loss of any part, deformity, paralysis, joint pain, arthritis, or other problem in foot, ankle, knee, hip, or
27.
other lower extremity.
28. Frequent or severe headaches:

Current Previous Never 28.1 Migraine headaches

Current Previous Never 28.2Tension or other headaches

Current Previous Never Have you been diagnosed with a condition affecting the nervous system that results in weakness or
29.
sensory loss such as multiple sclerosis, Parkinson’s disease, or stroke?
Current Previous Never 30. Seizures or epilepsy

Current Previous Never 31. Frequent feelings of being sick or easily tired, anemia, or bleeding tendency

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Current Previous Never 32. Chronic fatigue syndrome or fibromyalgia syndrome

Current Previous Never 33. Insomnia, difficulty sleeping, or sleepwalking

Current Previous Never 34. Tumors, cancers, leukemia, chemotherapy, radiation therapy, or organ transplantation

Current Previous Never 35. Blood disorder (sickle cell, anemia, and so forth)

Current Previous Never 36. Endometriosis, painful menstruation, abnormal vaginal discharge, uterine or ovarian tumors or cysts

Current Previous Never Other diseases or problems with your physical health not already noted, including family history of HIV,
37.
AIDS, tuberculosis, or other disease
Current Previous Never 38. Surgery, hospitalization, or injuries not listed above

39. Learning difficulties:

Current Previous Never 39.1 ADD or ADHD

Current Previous Never 39.2 Dyslexia

Current Previous Never 39.3 Diagnosis of autistic spectrum disorder (Aspergers, autism) or other developmental disorder

Current Previous Never 39.4 Reading disorder

Current Previous Never 39.5 Other learning disorders (including speech disorders)

40. Emotional difficulties:

Current Previous Never 40.1 Anxiety

Current Previous Never 40.2 Bipolar disorder

Current Previous Never 40.3 Depression (including suicidal plans or attempts)

Current Previous Never 40.4 Obsessive-compulsive disorder

Current Previous Never 40.5 Panic attacks including hyperventilation

Current Previous Never 40.6 Separation anxiety (homesickness)

Current Previous Never 40.7 Self-harm due to cutting, burning, scratching, etc.

Current Previous Never 41. Difficulty in relationships due to temper, moods, or habits (fights or aggressive behavior)

Current Previous Never 42. Schizophrenia or psychosis

Current Previous Never 43. Anorexia (deliberately skipping meals or eating small amounts), bulimia, and binge eating

Current Previous Never 44. Abuse of or dependency on prescription or over-the-counter medications, recreational drugs, or alcohol

Current Previous Never 45. Been a victim of physical, sexual, or emotional abuse from which you still suffer effects

Current Previous Never 46. Undiagnosed aches and pains

Current Previous Never 47. Professional counseling, treatment, or hospitalization for emotional problems

Current Previous Never 48. Other emotional problems

Yes No Can work 12 to 15 hours per day, walk 6 to 8 miles per day, ride a bicycle 10 to 15 miles per day, and
50.
climb stairs daily
Yes No 51. Will you receive vaccinations (including the COVID-19 vaccine)

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Declaration and Authorization by Missionary Candidate

I declare that the statements made in the Personal Health History of Missionary Candidate are a complete and
honest report of my health history. No personal health information has been withheld or misrepresented.

I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other
countries for Church purposes my personal data, including sensitive data, in accordance with the Church's
Global Privacy Notice.
Missionary candidate's signature Date
   
Parent or guardian's signature Date
   

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 Renato G. Gerong
Brgy Tampoong
Sogod, Sogod
6606 Southern Leyte
Philippines
First Name (middle) Last Name (Legal Name) (suffix) Record number Date of birth (Age) Gender
Kevin Carl Vasquez Reviso 0010080345211 26 Aug 2003 (19) Male

40.1 Anxiety
You are presently having problems related to anxiety or worry. (If yes, rate the level of your anxiety or worry and the problems they cause on this scale:)
1 2 3 4 5
Yes No Minor problem Serious problem

Indicate which of the following characteristics you have now or have had in the past (check all that apply).

Restlessness or feeling on edge Sleep problems

Difficulty concentrating; mind going blank Panic attacks (periods of intense fear or discomfort)
Muscle tension Fear of being embarrassed in social or performance situations (speaking, performing in
public, and so on)
Becoming fatigued easily Persistent inappropriate or unwanted thoughts, images, or impulses
Irritability (becoming irritated easily)

Describe your present or past anxiety, including frequency of occurrence and the causes.
hard
Indicate how long you have been feeling worried and anxious or how long ago these feelings stopped.
months
Which treatments have you received (check all that apply)?
Counseling
Medication
Hospitalization
No treatment
You plan on taking medication for this condition on your mission. (If yes, describe your current medications: name, dosage, and frequency.)
Yes No
As a missionary, you will be able to work a regular schedule: 16-hour day, including studying scriptures, tracting, obeying rules, learning and teaching lessons, giving
talks, getting along with companions. (If no, specify what you will be unable to do.)
Yes No

Medications
List any additional medication (prescriptions, over-the-counter drugs, or vitamins and supplements), including dosage and frequency, you are currently taking that has not
been previously listed.
none
Describe any negative reactions or allergies you have had to drugs or medication.
none

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