ITS Health Information Form
ITS Health Information Form
ITS Health Information Form
Does the student have any recurring medical problems or chronic conditions? No Yes. If yes, please tick any that apply:
Anemia/blood disorder Eating disorder HIV Migraines/headaches
Asthma Hypertension Kidney disease Mobility limitations
Autism/Asperger’s Syndrome Diabetes Learning disability Tuberculosis
Lupus Cardiovascular disease Mental health concern Color blind
Attention deficit hyperactivity Other, please specify:
Epilepsy
disorder (ADHD/ADD)
Health Information 1
PART C: CURRENT MEDICATIONS AND NEEDS
Student’s Name:
Last First/Given Middle
Date of
Gender: Male Birth: Country of Citizenship:
Female __ __ __ __ __ __ __ __
dd mm yyyy
Department/Degree: Duration of program (start date and end date):
- - - -
country code Area code number country code area code number
Diet
Do you require a special diet? Yes No
If yes, please give details:
Are there any foods that you
Yes No
cannot or should not eat?
If yes, please give details:
Allergies
Do you have allergies to:
Food Yes No If yes, please specify:
Medicines Yes No If yes, please specify:
Others Yes No If yes, please specify:
What medications can you be given for an allergic reaction?
Medications
Do you take any medications? *)**)
If it is a prescription, is it
Brand Name Generic Name Dose, Schedule, Special Instruction
renewable?
Yes No
Yes No
Yes No
*)Please ensure sufficient supply for the study’s duration.
Special Needs
Do you have any special needs or require any specific support? Yes No
**)Bringing any specific medical documentation would be very helpful for a doctor in the host country. Bringing it with you can help avoid
unnecessary and expensive procedures. It is recommended that you discuss this with your regular physician.
PART E: CERTIFICATION
Health Information 2
I certify that all responses made on this form are true, accurate and complete, and I will notify ITS IO of any relevant changes that
may occur prior to or during my study program. I have included in this form, advised the ITS IO Staff of any special needs or
assistance that I/the student may have relating to my/the student’s physical and mental health. I am aware that if I do not provide
complete information, this may cause hardship and concern to others and may affect my/the student’s own welfare. I understand
that if I do not provide complete information, ITS IO may decide to send me/the student home from the study program at my/the
student’s own expense.
I consent to the release of medical information to ITS IO or its agents so that they may provide me with needed assistance. I
further agree that ITS IO or its agents may release information to other persons who may need this information to assist me/the
student or to assist others in my study. I understand and agree that this form may be released to the ITS IO staffs for such
purposes.
I am aware that I am responsible for my/the student’s physical and mental health and will cover any medical expenses that may
occur during my/the student’s study at ITS.
If my parents or guardians have not signed this form, I represent and certify that I am not a minor according to the laws of my
country.
Tick if this is the case
Signature of Student:___________________________________________
Date: __________________
Signature of Parent/Guardian
of student: ____________________________________________________
Date: _________________
Health Information 3