Willamette University

Spanish and Liberal Arts in Granada, Spain

Self Disclosure Medical Form

This form is to help create awareness of any health issues that you should take into consideration before going abroad. This information will be used to guide us in assessing resources available at the site of your program. Please be thorough and complete with any comments and explanations. This information may be used in an emergency if you are unable to give the information yourself. Failure to disclose complete and accurate information may be grounds for dismissal from the study abroad program. Universities do not use this form when considering acceptance/denial to the study abroad program.

This information is secure and will only be used by those directly involved in the administration of the program. If you would prefer a paper copy of this form please contact Stacy West in the Office of International Education at Willamette.

Health History

Last Name(s): (as it appears on your passport)
First Name(s), Middle Name(s): (as it appears on your passport)
Pre-existing Health Conditions: List any pre-existing health conditions. If you do not have pre-existing health conditions enter NONE.
Current Major Illnesses: List any current major illnesses. If you do not have any current major illnesses please enter NONE.
Treatment While Abroad?: If you listed any health conditions or illnesses under the second and/or third question answer this question: Do you plan to continue treatment while abroad?
If YES.: If yes, how will you receive treatment?
If NO.: If you do not plan on continuing treatment, what will you do to maintain your health while abroad?
Current Medical Treatment: Do you currently receive any treatment or medication on a regular basis (write YES or NO)? If yes, please explain.
Major Surgery: Have you ever had a major surgical operation or been advised to have one (write YES or NO)? If yes, please explain and provide approximate date.
Hospitalization: Have you ever been hospitalized (write YES or NO)? If yes, please explain and provide approximate date.
Psychological/Mental Health: Have you ever been treated by a psychologist, psychiatrist or counselor for any mental, emotional or nervous disorder including depression, anxiety or sleep disorder (write YES or NO)? If yes, please describe.
Current Treatment: Are you currently receiving any treatment for depression, anxiety or sleep disorder (write YES or NO)? If yes, please describe.
Allergies: Please list any allergies. If you do not have allergies please write NONE.
Medications: Please list any medications you take on a regular or semi-regular basis.
Medication While Abroad: Will you bring enough of all of your medications to cover the entire time you are abroad? Write YES, NO or N/A.
If NO: If no, how will you obtain the necessary medication abroad? Please note: Mailing drugs internationally can be illegal. Consult the Consulate and your health care professional for specific restrictions and possible resources

Habits

Smoking: Do you smoke or use other tobacco products?
Yes, often
Yes, rarely
No, never
Alcohol: Do you drink alcohol?
Yes, often
Yes, sometimes
Yes, rarely
No, never
Caffeine: Do you consume caffeine beverages?
Yes, often
Yes, sometimes
Yes, rarely
No, never
Exercise: Do you exercise? If yes, describe the form of exercise, how often you exercise and how much?

Tools

Do you use any of the following items (write YES or NO)? If yes, give any necessary relevant details about the tools.
Contact Lenses?:
Eye Glasses?:
Hearing Aids?:
Prosthetic Joints?:
Other Devices?:

Other Medical/Wellness Issues?

Is there anything not mentioned on this form regarding your health and wellness that we should know about (write YES or NO)? If yes, please explain. (If you have questions about what may or may not be relevant you can call the Office of International Education at Willamette University to discuss specifics. Information will always remain confidential.)

Other:

Agreement

By checking the box labeled "Agree" and typing my name I authorize that, to the best of my knowledge, the information I have provided in form is my own information, that the information is accurate and that the information is complete.
Agree/Disagree: Agree
Disagree
Applicant Full Name:
Email Address - a confirmation of submission will be sent to this address: