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HEALTH FORM ADDENDUM NH11

Home Country____________________

(Give original to your US host family, make 2 copies- give to the Director at your US arrival orientation site & AFS Office in your country)

Participants First Name_________________________________ Last Name __________________________________


Physician please complete prior to participants departure.
A) Height_________

Weight_________

Blood Pressure ___________

Pulse ____________

1) Has participant had a substantial weight loss since completion of YES application?
Yes [ ] No [ ]
If yes, why?
_______________________________________________________________________________________________________
2) Has participant been hospitalized since completion of the YES application?
Yes [ ] No [ ]
If yes, when, why and outcome:
_______________________________________________________________________________________________________
3) Is the participant currently on medication?
If yes, why, name of medication, dosage, frequency

Yes [ ]

No [ ]

_____________________________________________________________________________________________________________________

4) Is there a history of, or present evidence of emotional, nervous or mental disorder?


Yes [ ] No [ ]
If yes, attach in a sealed envelope a full report by the specialist and a statement by the participant concerning the specific problem.
===================================================================================================
B) Immunization against the seven childhood diseases - Measles, Mumps, Rubella, Diphtheria, Pertussis, Tetanus and Polio are mandatory for entrance into U.S. schools. Additionally, schools require proof of infection (month and year) or immunization
(day, month, year) of Varicella (Chicken Pox). Immunizations for Hepatitis A and B are also required. The immunization
information will only be accepted if the EXACT MONTH, DAY, and YEAR of each vaccination is recorded. If the student arrives in
the United States without complete records and immunization within the past five years, the student will be denied admittance until
the missing immunizations are given at the cost of the natural family.
To avoid these added expenses ensure the applicant receives ALL the necessary immunizations before leaving home.
The applicant has had the following immunizations:
Yes

Dy/Mo/Yr

Dy/Mo/Yr

Dy/Mo/Yr

Dy/Mo/Yr

Measles

____

____________

____________

____________

____________

____________

Mumps

____

____________

____________

____________

____________

____________

Rubella

____

____________

____________

____________

____________

____________

Diphtheria

____

____________

____________

____________

____________

____________

Pertussis

____

____________

____________

____________

____________

____________

Tetanus

____

____________

____________

____________

____________

____________

Hepatitis A

____

____________

____________

____________

____________

____________

Hepatitis B

____

____________

____________

____________

____________

____________

Polio

____

____________

____________

____________

____________

____________

Varicella

____

____________

____________

____________

____________

____________

BCG

____

____________

____________

____________

____________

____________

________

____

____________

____________

____________

____________

____________

TB Test

____

Which type: Mantoux or Tine?

If positive, was chest x-ray done?

Yes [ ]

No [ ]

Dy/Mo/Yr

Date ____________

Result

____________

Date ____________

Result

____________

I, the undersigned, certify that all important recent medical information has been included, that nothing relevant has been omitted
and that the participant is able to travel abroad.
Physicians Name: _________________________________________________ Address:

____________________________

Signature:
_________________________________________________ Date: ________________________________
===================================================================================================
C) PARENTS, please complete this section: In the event of a medical emergency we, the natural parents of the participant,
authorize the YES hosting organization to obtain emergency medical treatment if required by a situation due to an accident or
unanticipated illness. Authorization is also given for immunizations and x-rays.

We are also aware that due to some USA state school requirements students may be required to receive additional vaccines
before registration and at the cost of the participant.

Fathers Signature __________________________________ Mothers Signature _____________________________________


Date:
__________________________________ Date:
______________________________________

2 April 2010

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