This form is for the safety of the students involved with the Honors UGA-IFP. The questionnaire will be kept confidential and will be reviewed only by the program senior staff. The information provided will be given to others (medical personnel, staff, etc.) only in an emergency situation, or when deemed necessary by the faculty/staff. This form is for your protection, the more complete the form, the better the medical treatment you may receive, if needed. IMPORTANT: If you know or suspect that you have some medical situation that may be aggravated by intense field work and the situation is not covered in any of the questions in this form, you MUST explain it in section 9, at the end of this form. Also, if you discover at any point before or during the trip that you need to amend this application (i.e. discover you have the hepatitis-B virus), you MUST do so as soon as reasonably possible. Failure to comply with the instructions in this form or disclose any pertinent information may result in your dismissal, without refund!

Please print legibly or type.

Name: ________________________________________

last, first middle

Sex: male female (please circle one)

Social Security #: __________________

Student ID# (if different): ___________________

Age: _______ Date of Birth: ____________

Height: _________ Weight: ____________

Health Insurance Company that you are covered under: _____________________________________

Policy Holder's Name: _________________________________

Policy Number: ____________________________

Insurance Company's Phone Number: _____________________________________

Include a clear, legible copy our health insurance card (front and back) and attach it to this form.

1. Family Medical History

Check the appropriate space for any serious illness you are aware of that has occurred in a blood relative (grandparents, parents, brothers, sisters, children, etc.):

_____ anemia _____ high blood pressure _____ thyroid disorders

_____ ulcers _____ bleeding tendency _____ migraine headaches

_____ cancer _____ rheumatoid arthritis _____ heart problems

_____ HIV positive _____ tuberculosis _____ diabetes

_____ stroke _____ other (explain)

Explain any checked item above and add anything not listed: _____________________________

_____________________________________________________________________________________

____________________________________________________________________________________.

Please check the appropriate space for any illness that you have had in the past or have now:

_____ anemia, sickle cell _____ anemia, other _____ meningitis

_____ gout _____ mononucleosis _____ headaches, migraines

_____ asthma _____ phlebitis _____ bleeding tendencies

_____ eating disorders _____ pneumonia _____ bronchitis

_____ heart disorders _____ rheumatic fever _____ cancer

_____ hepatitis _____ HIV positive _____ colitis

_____ hypoglycemia _____ hyperglycemia _____ stroke

_____ diabetes _____ high blood fats _____ thyroid disorders

_____ intestinal parasites _____ tuberculosis _____ frequent ear infections

_____ kidney stones _____ ulcers _____ breast fibrocystis

_____ malaria _____ rheumatoid arthritis_____ gallbladder disorders

_____ depression

Explain any check above and add any situation is not listed: ____________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________.

Please check any of the following that apply.

_____ insect bites or stings _____ animal hair/dander

_____ pollen (hay fever) _____ foods (specify below)

_____ other (specify below)

Explain any checks above here, if necessary: _________________________________________________

_____________________________________________________________________________________.

Please check the appropriate space for any drug to which you know or suspect you are allergic:

_____ penicillin _____ pain medicine (i.e. codeine, morphine, etc.)

_____ ampicillin _____ Demerol

_____ sulfa drugs _____ Novocain or other local anesthetic

_____ tetracycline _____ tranquilizers (i.e. Librium, Valium, etc.)

_____ aspirin _____ erythromycin or other "mycins"

_____ X-ray dyes _____ sleeping pills (i.e. Seconol, Nembutal, etc.)

_____ vaccine sera _____ others (specify below)

Explain any of the checks above and detail any symptoms to typically have: ________________________

_____________________________________________________________________________________

____________________________________________________________________________________.

Please check the appropriate space for any drugs that you are currently using or use regularly:

_____ amphetamines _____ cough medicine _____ diet pills

_____ antacids _____ muscle relaxants _____ menstrual cramp medicine

_____ antihistamines _____ diuretic _____ nasal spray

_____ allergy shots _____ ear drops _____ Ritalin

_____ antibiotics _____ eye drops _____ pain medication

_____ antidepressants _____ epilepsy medication _____ sleeping pills

_____ aspirin _____ headache medication _____ thyroid medication

_____ asthma medication _____ heart medication _____ skin medication

_____ barbiturates _____ hormones _____ tranquilizers/sedatives

_____ birth control pills _____ insulin _____ vitamins (specify below)

_____ blood pressure medication _____ iron supplements _____ laxatives

_____ cortisone _____ other (specify below)

Explain any check above and add anything not listed: __________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________.

Please give the most recent year you were immunized or tested for the conditions below. If it was more than 10 years ago, you can just indicate "childhood". If you are not sure, check the dates with your doctor, or have the procedure done again.

IMPORTANT: We require a tetanus immunization or booster within the last 10 years in order to participate in the Honors Geology and Anthropology Summer Field Program. UGA also requires a measles vaccination before registration. If you are not a UGA student, you must make arrangements with health services (706) 542-8619 to fill out a vaccination form. This form must be completed and sent the UGA health services before you register.

__________ DTP (usually given at infancy)

__________ Measles/mumps/rubella

__________ Polio

__________ Tetanus or tetanus/diphtheria

__________ Tuberculin skin test (result was: _____ positive _____ negative)

__________ Chest X-ray (if skin test was positive)

(result was: _____positive _____ negative)

If positive, describe treatment in section 9.

Do you have any illness (including depression) or injury that requires you to consult a physician or other health care professional on a periodic basis? _____ yes _____ no (If yes, explain below.)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________.

You wear: _____ glasses _____ contact lenses _____ none.

If you wear either glasses or contacts, can you:

pass a driving test without them? _________

read comfortably without them? _________

see anything without them? _________

Do you tend to experience:

carsickness: _____ yes _____no _____ don't know

seasickness: _____ yes _____no _____ don't know

dizziness due to heights: _____ yes _____ no _____ don't know

poor night vision: _____ yes _____ no _____ don't know

Are you on a restricted diet for any medical reason? _____ yes _____ no

If yes, explain: _________________________________________________________________________

_____________________________________________________________________________________.

Do you prefer to avoid animal products in you diet?

_____ no

_____ yes, don't eat the following;

_____ red meat _____ fish, seafood _____ poultry _____ eggs _____ dairy products

Do you regularly drink beverages containing caffeine?

_____ no

_____ yes, usually drink the following;

_____ coffee _____ tea _____ cocoa _____ colas _____ other

I usually drink _____ cups/glasses/cans a day, on average.

Is there ANYTHING in your medical history or present health status that has not been covered in this form, and which you think we should be aware of in order to help you participate in the Honors Geology and Anthropology Summer Field Program safely? Please explain fully, and attach additional pages if necessary.

____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________.

Name of personal physician: ________________________________

Address: ___________________________

___________________________

___________________________

Phone: (_____) ___________________

List two individuals below who could be notified in case of an emergency (i.e. parents, spouse, sibling, close family friend, etc.).

1. Full Name: ___________________________

Address: _____________________________

_____________________________

Home Phone: (_____) __________________

Work Phone: (_____) __________________

Relationship: _________________________

2. Full Name: ___________________________

Address: _____________________________

_____________________________

Home Phone: (_____) __________________

Work Phone: (_____) __________________

Relationship: _________________________