Discipleship Training School (DTS) Medical Form

Full Name Full Name Title First Middle Last Suffix
Please insert your name as seen on your passport.
Email
Gender
Date of Birth Date of Birth / DD / MM YYYY
Full Name of Emergency Contact Full Name of Emergency Contact First Last
This will be the person we will contact in the case of an emergency
Relationship to you
Their preferred contact number

Please include the international code
Their email address
In case we cannot reach your emergency contact, is there someone else we can try?

Enter the same details above or write "No"
Do you consider yourself to have a disability, impairment or long-term condition?

Do you consider yourself to have a disability, impairment or long-term condition? No Yes
If yes, please indicate:

If yes, please indicate: Hearing/Deaf Intellectual Mental Illness Physical Learning Acquired Brain Impairment Vision/Blindness Medical Condition Other Other
Have you ever had any of the following?

Have you ever had any of the following? Skin Trouble Eye Trouble Ear Trouble Head Injury Recurrent Headaches Migraines Epilepsy Fainting Spells Weakness Paralysis Insomnia Sleep Apnoea Other Sleep Disorder Shortness of Breath Hay Fever/Asthma Heart Trouble High Blood Pressure Low Blood Pressure Rheumatism/Arthritis Back Problems Dislocated Joints Broken Bones Anorexia/Bulimia Anxiety/Depression Other Mental Illness Stomach/Duodenal Ulcers Gall Bladder Problems Jaundice Intestinal Troubles Recurrent Diarrhoea Chronic Constipation Diabetes Kidney Disease Anaemia Tumour Cancer Chronic Fatigue Venereal Disease Other None of the Above

If you have not had any of the following, tick the "None of the Above" box
Please give details on each of the items ticked
Have you ever had any of the following Communicable Diseases?

Have you ever had any of the following Communicable Diseases? Chicken Pox Pertussis (Whooping Cough) Hepatitis Measles/Rubella Scarlet Fever HIV/AIDS Mumps Tuberculosis Other None of the Above

If you have never had any of these diseases, please check "None of the Above"
Please give details for each of the items ticked
Do you have any allergies?

Do you have any allergies? Yes No
Please select the type of allergy/ies you have

Please select the type of allergy/ies you have Food Drugs/Medication Other
Please provide details about your allergies including the allergen, your reaction and the strength of the reaction (ex. Dairy, diarrhoea, mild)
Have you ever had surgery?
Please give details including the date and type of procedure and any ongoing complications
Are you pregnant?

Are you pregnant? Yes No
When is your approximate due date?
Do you experience:

Do you experience: Severe Menstrual Cramping Excessive Menstrual Flow Irregular Periods Extreme Mood Swings associated with PMS None of the Above
Are you currently taking any medication?

Are you currently taking any medication? Yes No
Please give details
Are you medically required to eat a special diet?

Are you medically required to eat a special diet? Yes No

Please include any dietary requirements/needs that are relevant for our Kitchen Staff (i.e. lactose-free, gluten-free, vegetarian, vegan, etc.).
Please give details
Is there any family medical history that we should be aware of?

Is there any family medical history that we should be aware of? Yes No
Please give details
Do you suffer any condition currently under the care of a doctor?

Do you suffer any condition currently under the care of a doctor? Yes No
Please give details
Have you ever received compensation for disability from any source?

Have you ever received compensation for disability from any source? Yes No
Please give details
Please give details if there is anything not mentioned above that you would like to tell us about
Declarations

Declarations I have completed all questions on this form truthfully and to the best of my knowledge.

Please check all of the boxes