confidenal medical form - ywamdp.org · this confidenal medical form has two ......
TRANSCRIPT
NameofApplicant School
IMPORTANT:ThisConfiden7alMedicalFormhastwoparts:PartAistobecompletedbytheapplicantandreviewedbyaPhysician,Physician'sAssistantorNursePrac77onerPartBistobecompletedbyaPhysician,Physician'sAssistantorNursePrac77oner
Areyoupresentlyunderadoctor'sorcounselor'scareforanycondi3on? Yes NoSpecify
DoyouhaveanyphysicalchallengesthatcouldhinderyourexperiencewithYWAMDP? Yes NoSpecify
Doyouhaveanyallergies?(i.e.food,medicines,bees3ngs,etc) Yes NoSpecify
Doyouhaveany medical doctor diagnosed food alergies such as Ciliac or lactose intolarence?) Yes NoSpecify
Doyouuse(orhaveyouused)tobaccoproductsofanykind? Yes NoSpecify
WhatisyouropinionoftheuseofMarijuanaorotherillegaldrugs?
Areyoupresentlytakingmedica3onsofanykind? Yes NoSpecify
Confiden7alMedicalForm
Month/YYYY
TheapplicantnamedabovehasappliedforadmissiontoaUniversityoftheNa7onsaccreditedprogramataYWAMDes7na7onParadisebase.YWAM(YouthWithAMission)isaninterna7onal,interdenomina7onalChris7anmissionaryorganiza7on.Foundedin1960,YWAMnowhascentersinover1000loca7onsinover135countriesaroundtheworld.YWAM'spurposesincludetraining,challengingChris7anstofulfillthecommandofJesusto"Gothereforeandmakedisciplesofallna7ons..."havingthedesireto"knowGodandmakeHimknown".Formoreinforma7onaboutYWAMandYWAMDes7na7onParadise,pleasevisitourwebsitewww.des7na7onparadise.org.
PartA‐tobecompletedbytheapplicantandreviewedbyaPhysician,Physician'sAssistantorNursePrac77oner
NameofApplicant School
IMPORTANT:ThisConfiden7alMedicalFormhastwoparts:PartAistobecompletedbytheapplicantandreviewedbyaPhysician,Physician'sAssistantorNursePrac77onerPartBistobecompletedbyaPhysician,Physician'sAssistantorNursePrac77oner
Height Weight Overweight? Yes No
BloodPressure Pulse BloodType
SystemsSurvey(pleasecheckeachandcommentonanyirregulari7esorrecommenda7onsforfollowup)
E.N.T. Comments
Ophthalmological
Teeth
Neurological
Cardiovascular
Respiratory
Physician'sRecommenda9onsAcceptablewithoutlimita7ons Acceptablewithlimita7ons Notacceptable
Comments
Physician'sName(PleasePrint)
Address
Phone
Physician'sSignature Date
Musculoskeletal
Endocrine
Lymphatic
Dermatological
Psychiatric
Confiden7alMedicalForm
Month/YYYY
TheapplicantnamedabovehasappliedforadmissiontoaUniversityoftheNa7onsaccreditedprogramataYWAMDes7na7onParadisebase.YWAM(YouthWithAMission)isaninterna7onal,interdenomina7onalChris7anmissionaryorganiza7on.Foundedin1960,YWAMnowhascentersinover1000loca7onsinover135countriesaroundtheworld.YWAM'spurposesincludetraining,challengingChris7anstofulfillthecommandofJesusto"Gothereforeandmakedisciplesofallna7ons..."havingthedesireto"knowGodandmakeHimknown".Formoreinforma7onaboutYWAMandYWAMDes7na7onParadise,pleasevisitourwebsitewww.des7na7onparadise.org.
Hernial Orifices
Urological
PartB‐tobecompletedbyaPhysician,Physician'sAssistantorNursePrac77oner(pleasereviewPartA)