LISLE INC.
900 County Road 269
Leander, TX 78641
1/800-477-1538 email: lisle@io.com
MEDICAL EXAM FORM AND AUTHORIZATION OF EMERGENCY TREATMENT
MUST BE COMPLETED AND RETURNED TO ABOVE ADDRESS PRIOR TO DEPARTURE
THIS INFORMATION IS SHARED WITH THE EXECUTIVE DIRECTOR AND PROGRAM LEADERS
This form should be completed by the physician and signed by the physician and the applicant on the reverse side. If the answer to any of the questions below is "Yes", please give details on a separate sheet. In each case, please indicate whether the condition is likely to affect the student’s full participation in the program.
Attn: Physician:
Please evaluate the physical and mental health of the below named applicant for an intensive intercultural program, often held abroad. An applicant will not be rejected due to either his/her physical or emotional condition unless it is of such serious nature as to prevent successful participation in the program. Information regarding his/her health, however, will be invaluable to the program staff in anticipating and dealing with any health problems with may arise during the program. Lisle suggests that those applicants traveling outside the United States should take with them an ample supply of any medication they will need. The physician is asked to describe and verify each drug in writing so as to avoid possible difficulties with airport and customs officials. Please add any details not covered by the questionnaire on the reverse side of this form. Your reply will be confidential.
AT THE END OF THE EXAMINATION, PLEASE ASK THE PATIENT TO READ THE STATEMENT AT THE BOTTOM OF THE FORM AND SIGN IN THE SPACE ALLOWED.
Applicant’s Name _________________________ Program _________________
Applicant’s general state of health: Excellent ___ Good ___ Fair ___ Poor ___
Applicant’s date of birth: ________________ Height ________ Weight _______
1. Is the applicant seriously underweight or overweight? Yes ____ No ______
2. Does applicant have any dietary restrictions or food allergies? Yes ____ No ______
3. Is applicant allergic to any form of medication? Please specify. Yes ____ No ______
___________________________________________
4. Does the applicant have any speech, hearing or eyesight impairment Yes ____ No ______
Which might affect his participation in the program?
5. Has applicant any physical disability, which might cause hardship Yes ____ No ______
through change in diet, carrying luggage, or strenuous travel?
6. Is there any congenital malformation now existing that may require Yes ____ No ______
additional treatment? If "yes", what is this condition and what
treatment is to be pursued?
7. Is the applicant currently under treatment or observation for any Yes ____ No ______
physical or emotional condition which might affect participation
in this cross cultural education experience?
8. Is there any history of emotional disturbance in the applicant? Yes ____ No ______
Has he/she shown any:
a) difficulties in relationships with parents, authority figures Yes ____ No ______
peers?
b) behavior disorder? Yes ____ No ______
c) symptoms such as mood swings, depression, severe sleep Yes ____ No ______
disorders, unusual degree or anxiety, fear or guilt?
9. Does the applicant have any communicable or infectious disease? Yes ____ No ______
10. To your knowledge, are there any predisposing medical, surgical Yes ____ No ______
or emotional factors which may, under stress or duress during
program, present a need for immediate therapy while abroad?
11,Please list medications presently taking:
________________________________________________________________________________-------------------------------------------------------------------------------------------------------------------------------
We suggest the following tests and immunizations:
Tuberculin Skin Test: Performed ___________ Read ________________mm. in duration
It is suggested that the patient also have the tuberculin skin test upon return to the United States.
Dip./Tet. Date ____________ Poliomyelitis Date: ____________
Physician’s Name _______________________________________________
Address _______________________________________________
_____________________Phone _____________________
Physician’s Signature _________________________ Date ______________
TO THE PARTICIPANT: Failure to provide complete and accurate information during this examination can result in termination of your participation in the program.
Please read the following and sign where indicated:
I, the undersigned, hereby affirm that I have provided complete and accurate answers regarding my physical and emotional history during this examination and also that I am fully aware of the possible consequences of falsification of this data as stated above.
I hereby authorize emergency treatment of myself, if, in the opinion of the Lisle program leader and/or attending physician, that emergency treatment is necessary to safeguard my health. If participation is terminated during the trip, I understand that I am responsible for all costs incurred in early return from the host country.
Signed by: _________________________________ Date: ________________
Parents signature required if participant is under 18:
Parent: ___________________________________ Date: ________________
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