Community College of Allegheny County International Travel Health Form
In order to protect and secure the health and safety of our students while traveling, each student must submit a health form signed by his/her physician. All information is confidential. In the event of an emergency the information may be given to the appropriate medical authority. Today’s Date: _____________________ Name:________________________________________________________________________ Address: ______________________________________________________________________ ______________________________________________________________________________ Phone:_________________________ Birthdate:___________________ Gender: ____________
CONDITIONS Is there any history or current evidence of: Mobility Limitations YES____ NO_____ Life-threatening Allergies YES____ NO_____ Psychological Conditions YES____ NO_____
Pulmonary Disorder
YES____ NO_____
Seizure Disorder
YES____ NO_____ YES____ NO_____ YES____ NO_____
Sleep Disorder
Diabetes Type 1/Type 2
YES____ NO_____
Heart Condition
Visual Impairment (not corrected) YES____ NO_____ Auditory Impairment (not corrected) YES____ NO_____ Other _________________________________________________________________________ For any YES responses please explain the type, severity, and impact, if any, on program participation. ______________________________________________________________________________ ______________________________________________________________________________
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