PHYSICIAN'S VERIFICATION FORM
Name of Applicant: _________________________________________ Date: _____________________
Name of Physician: _________________________________________
Address of Physician: _______________________________________
_______________________________________
Phone Number of Physician: __________________________________
MEDICAL HISTORY
How would you describe the patients general health?
How would you describe the patient's physical condition?
Please list ALL medications taken during the past two years.
Does the patient have any allergies to any medications? If so, please list.
Does the patient have any other allergies (include insects)? Please list.
Does the patient have any medical conditions that will preclude them from exposure to or from participating in rigorous physical activities, poor quality food or drinking water, or circumstances of travel via plane, canoe or local transport, none or poor medical facilities, endemic diseases (malaria, yellow fever)? YES NO
If YES, Explain:
Hepatitis B vaccine series (required) _________ _________ _________
Hepatitis A vaccine series (suggested) _________ _________
Yellow Fever (suggested CDC) _________
Signed: _______________________________ Date: _____________________
********************************************************************************************
Dr. ______________________ has my permission to complete this medical form and release the information to the [university] and GAI only for purposes of travel to Iquitos, Peru.
Student Participant: _____________________________________ Date ___________________
********************************************************************************************
Form is to be completed and returned by February 15 to: Global Awareness Institute (GAI)
2208 S.E. 20th Street
Fort Lauderdale, FL 33316