Download Northern Exposure Medical Form

Livnot U'Lehibanot – To Build and To Be Built
Tel: 1-8888-LIVNOT (1-888-854-8668) Fax: (718) 907-7997 Email: [email protected]
THIS FORM SHOULD BE SENT BY E-MAIL OR FAX, NOT IN THE MAIL
NORTHERN EXPOSURE MEDICAL INFORMATION FORM
Applicant's Name:
Height:
Date of Birth:
Weight:
1. Do you have: Any Addictions, Asthma, Epilepsy, Heart Disease, Tuberculosis, HIV /
AIDS, Mental illness, Nervous breakdown, Neurological problems, Depression, Venereal
diseases, Diabetes, other diseases or disorders? If none, please mark “None”. If yes, give
details:
2. Please detail any other condition (major surgery, pregnancy, allergies, etc.). If none,
please mark “None”.
3. Please detail any history of psychological or emotional problems. If none, please mark
“None”.
4. Are you on (or were you recently on) any prescription medication? Please list name(s) of
drug(s), dosage(s) and reasons for the medication. If none, please mark “None”.
5. Are you able to perform the following:
a. Able to perform physical labor for 2 hours - yes / no
b. Walk a distance of 10 -15 miles in one day - yes / no
6. Please rate your physical state: excellent / good / fair / poor
7. Please rate your mental/emotional state: excellent / good / fair / poor
8. Are you capable of working with others on a regular basis? Yes / No
9. Overall comments: Is there anything else we should know about your physical or mental
health?
Disclaimer - "Providing false information, or failure to provide truthful information, or withholding of
relevant medical/psychiatric information on this form or in the interview, is basis for immediate dismissal
from the program. Any expenses incurred through this dismissal are to be paid by the participant. Livnot
takes no responsibility for damages – physical, psychiatric, or financial – that are sustained by someone
withholding relevant information."
I confirm that all information I have written on this form is accurate and correct.
Signature _________________
Name ________________ Date ____________