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STUDENT HEALTH CERTIFICATE

CERTIFICATE OF DENTAL HEALTH

I have examined the teeth of this student and certify that they are in satisfactory condition.

Dentist’s Signature: ______________________________________________________________________ Date: _______________________

Dentist’s Name Printed: _______________________________________________________________ Phone: (________) ________________

Area/City Code

Dentist’s Address: ____________________________________________________________________________________________________

CERTIFICATE OF GENERAL HEALTH

Physicians, Please Note:

Dear Medical Provider,

In completing this medical form, please know that this student has applied to be a YFU exchange student and upon acceptance will travel to another

country to live with a host family and attend school. The completed physical form is a very important document if the student has any medical issues

while on the exchange program. Please provide as much detail as possible on any health issues that may need attention while the student is living

abroad. The exchange experience can be challenging both physically and emotionally for a student, and we request that this be taken into consideration

when completing this health form. Our goal is to provide the best possible exchange experience for this student.

Please type or print legibly in BLACK INK and write in English. Upon completion of this form, return it to the student. Thank you for your assistance.

Student’s Name: __________________________________________________________________ Date of Birth: _______________________

Address: ___________________________________________________________________________________________________________

City State/Province Zip/Postal Code Country

Date of examination: ___________________________________ Sex: M F

For how long has this person been a patient of yours: ___________________________________

Height (cm): _________________ Weight (kg): _________________

Blood Pressure: Sys: ___________________ Dia: _______________________ Pulse rate: ______________________ Regular? Yes No

1. Has the student ever received treatment, attention or advice from a physician or other practitioner for, or been told

by any physician or practitioner that such person had:

1. Allergies* Yes No

2. Asthma Yes No

3. Appendicitis Yes No

Has appendix been removed? Yes No

4. Arthritis Yes No

5. Cancer Yes No

6. Chicken Pox (Varicella) Yes No

7. Diabetes Yes No

8. Eating disorder Yes No

(e.g. anorexia, bulimia)

9. Emotional difficulties Yes No

10.Enuresis/Bed wetting Yes No

11.Epilepsy Yes No

12.German measles (Rubella) Yes No

13.Hernia Yes No

Has applicant been operated on/for hernia Yes No

14.Malaria Yes No

15.Measles (Rubeola) Yes No

16.Mumps (Rabula inflans) Yes No

17.Pneumonia Yes No

18.Rheumatic fever Yes No

19.Scarlet fever Yes No

20.Serious or persistent cough Yes No

21.Serious or persistent headaches Yes No

22.Frequent or chronic strep throat Yes No

(Streptoangina)

23.Tuberculosis Yes No

24.Typhoid fever Yes No

25.Ulcers Yes No

26.Vertigo, dizziness Yes No

27.Whooping cough (Pertussis) Yes No

*For allergies, please indicate in section below type, allergen, frequency and severity of symptoms, duration, date of last symptom,

medication (name, oral or injected and dosage)

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

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Continued on next page

2. Any disease, impairment or abnormality of:

a. Blood or endocrine system Yes No

b. Bones, joints, or locomotor system Yes No

c. Brain or nervous system Yes No

d. Ears or hearing Yes No

e. Eyes Yes No

f. Genital-urinary system Yes No

g. Heart or blood vessels Yes No

h. Lungs, respiratory system Yes No

i. Other abdominal organs Yes No

j. Ovaries or breasts, if a female Yes No

k. Menstrual disorders, if a female Yes No

l. Prostate or testes, if a male Yes No

m. Skin Yes No

n. Stomach or digestive system Yes No

o. Throat Yes No

p. Thyroid Yes No

q. Tonsils, nose Yes No

Have tonsils been removed? Yes No

For all parts of Question 2 answered “yes”, please give details: (Please print) Identify Questions Nature and Severity of Disease or

Disorder, Specific Diagnosis, Frequency of Attacks and Treatment. If any conditions are chronic, please provide detailed information

regarding management of the condition(s).

(number or letter of condition)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

3. Has the student: If “yes”, please explain.

Additional comments may be made below if needed.

a.

Had any surgical operation not revealed in previous

questions, or gone to a hospital, clinic, dispensary or

sanatorium for observation, examination or treatment not

revealed in previous questions?

Yes No a

b. In the past 6 months taken any prescribed medication or

been advised to restrict diet or living routine?

Yes No b

c. Ever used cocaine, barbiturates or other addictive drugs,

except as medication prescribed by a physician or other

practitioner?

Yes No c

d. Ever received treatment from a physician or other

practitioner regarding the use of alcohol, or the use of drugs

except for medical purposes, or received treatment or advice

from an organization that assists those who have an alcohol

or drug problem?

Yes No d

e. Had any significant weight loss or gain? Yes No e

f. Participated in counseling or therapy within the last 2 years? Yes No f

g Ever exhibited symptoms of or been treated for an eating

disorder?

Yes No g

4. Do you have knowledge of any history or present evidence of nervous, emotional, or mental problems? For example, is there any history of

depression, suicidal thoughts or behavior, psychosis, mood swings or other nervous conditions? Yes No

If yes, please explain: ______________________________________________________________________________________________________

5. Is the applicant contemplating any surgical operation or planning to seek other medical advice or treatment? Yes No

If yes, please explain: ______________________________________________________________________________________________________

Additional comments (continue on extra paper if necessary): ______________________________________________________________________

6. Will the student be taking any prescribed medication with him or her? Yes No If yes, what medication?

a. Generic name, dosage and reason _________________________________________________________________________________________

b. Generic name, dosage and reason) ________________________________________________________________________________________

8. In my opinion the general state of the student’s health is: Excellent Good Fair Poor

9. In my opinion the student may participate in high school sports and activities: Yes No

Physician’s Signature: ___________________________________________________________________ Date: ___________________________________

Physician’s Name Printed: ________________________________________________________________ Phone: (________) _______________________

Physician’s Address: ___________________________________________________________________________________________________________

Health certificate