MEDICAL FORM II

PREEXISTING MEDICAL CONDITIONS

· This must be completed by the family physician if the student has any preexisting medical conditions. (Diabetes, history of illness, allergies, psychiatric problems, etc.)

Student Name: ________________________________________________

Name of Physician completing form: _______________________________

Physician’s phone number: ____________________

The “Journey East Sino-American Cultural Exchange Program” will be an intense four-week program that will require students to operate at their personal best. Our students will be expected to meet the physical and mental demands of their art form and the mental and physical stress of performing and living in a very unfamiliar cultural environment. Each student’s day will begin at or before 7 a.m. and will include performances, rehearsal and sightseeing. Long walks and extended rigorous activity are not uncommon.

Because of the demanding schedule, your feedback is invaluable to us. Does this student’s preexisting medical condition require the adults on this trip to take any precautions with regard to this student’s well being? Should the student’s activities be restricted in any way? Please complete this form and use the remaining space to give feedback regarding the student’s physical and mental condition.

Preexisting Condition(s):

List any current medications, both prescription and over-the-counter and the condition for which the medication was prescribed.

______________________ __________________ ______________

Medication Condition Dosage and Times

______________________ __________________ ______________

Medication Condition Dosage and Times

Additional Comments: Should there be any precaution taken with regard to this student’s well being? Please use the back of this form if you need additional space.

Physician Signature:_________________________ Date: _______________