Health Certificate PDF
Health Certificate PDF
Health Certificate PDF
2 Do you note any abnormalities concerning height, weight (including substantial loss or gain in the past six months), blood pressure, pulse or respiration?
No Yes (describe)
3 Please check the appropriate box. Has the candidate HAD any of the diseases/conditions listed below:
If yes, give detailed information and dates (use extra pages if necessary):
4 ACNE No Yes If yes, identify area, severity, any medication taken, name, dosage & frequency:
5 ALLERGIES No Yes If yes, identify type, any medication taken, name dosage & frequency:
6 ASTHMA No Yes If yes, identify type, severity, any medication taken, name, dosage & frequency:
7 DIABETES No Yes If yes, identify type, severity, any medication taken, name, dosage & frequency:
SEIZURE
8 No Yes If yes, identify type, severity, any medication taken, name, dosage & frequency:
DISORDER
9 Has the candidate ever had any disease, impairment or abnormality of:
11 Is the candidate currently taking medication or injections (other than those mentioned previously)? No Yes
If yes, identify the medication, reason for usage, dosage and frequency:
12 Has the candidate EVER consulted a neurologist, psychologist or any other specialist for a nervous, emotional or eating disorder? No Yes
13 Is there a history of, or present evidence of, an emotional, nervous or eating disorder? No Yes
If yes to either (12 or 13), a FULL report by the specialist and a statement by the candidate about the illness or specific problem must be attached in a sealed envelope.
Note: Placement in a foreign host family, school and community requires adjustment which often involves emotional stress. It will not be a time for relaxation or
temporary relief from any current therapy. If the candidate is experiencing current emotional, physical, personal or family difficulties, these difficulties can be severely
exacerbated by the adjustment demands of the AFS program. Therefore, you are requested to evaluate carefully the candidate’s current or previous condition and
treatment along with his or her ability to manage potential adjustment anxieties and stress in a foreign environment.
14 Are there any health limitations or restrictions on the candidate’s activities and/or sports participation, or any medical information
No Yes
which should be considered for a home/school placement?
DATE
16 What was the date of the candidate’s last dental check up?
FREQUENCY
If yes, will orthodontic care be needed while on the program? No Yes
17 Please specify exact day, month and year that the candidate had the following immunizations:
I, the undersigned, certify that a thorough physical examination of the candidate has been given and all important recent medical information has been included on
the health certificate, that nothing relevant has been omitted, and that the candidate is able to travel. I understand that the omission of any information could be
harmful to the candidate’s health care and could result in early termination from the AFS program.
ADDRESS DATE
Your signature below attests that you understand and accept the AFS Medical Policies as stated on the Participation Agreement, that the information on the health
certificate is correct and complete and that inaccurate or incomplete information could be harmful to the candidate’s health care and could result in early termination
from the AFS program.