Health History Form

"*" indicates required fields

We strive to support you during your CFHI experience. Depending on your personal circumstances, we may alter certain program components, such as lodging, or provide you with additional on-site support. Special accommodations, if any, will be discussed with you prior to your program start date.

To help us determine which programs, program components, or other on-site support may need to be adjusted in your situation, please fill out this confidential health history disclosure form at least 45 days prior to your program start date. Completion of this form is required to participate in your CFHI program. We will use this information solely for program-related purposes.

The information gathered on this form will not be shared with other participants and will be kept confidential among CFHI program staff in San Francisco and your on-site Local Coordinator and Medical Director, within the limits of applicable laws.

You should also take steps to prepare for participating in a CFHI program. If you know you have certain health conditions that could impact your participation in the program, please work with your doctor or health care provider to create an Action Plan. An Action Plan outlines the steps you should take if your physical or mental health condition returns or worsens when you are participating in a CFHI program.

Do you have any medical issues and/or have you ever in your lifetime been given any diagnoses by a health practitioner or mental health provider?*

Yes

If so, please list the medical issues you have experienced and/or diagnoses you have ever been given, as well as the year of diagnosis, if known.

Psychological/Mental Health History

Studying abroad can be an enriching experience. It can also be physically and mentally challenging. Even mild pre-existing mental health conditions can worsen due to the stress of adapting to an unfamiliar culture and environment and from being without regular support systems. All individuals adapting to unfamiliar cultures experience some level of stress related to this transition. Experienced travelers with mental health-related disabilities suggest setting up a support system in advance, even if you think you won’t need it. Be proactive and make sure you bring and continue your medication while on the program. Talk to your personal physician and to set up strategies for coping with the stress, whether it be a support network through remote telecommunications or daily exercise.

We strongly encourage all applicants to fully disclose their mental health history so that we can prepare them properly for their experience and make arrangements for any special accommodations. In-country counseling will be available to those students needing this service.

Please answer the questions below.

PHYSICAL HEALTH HISTORY

Headaches*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Epilepsy / seizures*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Asthma / lung disease*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Heart disease*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Anemia or bleeding disorder*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Ulcer / Colitis*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Hepatitis / gall bladder*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Bladder / kidney problems*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Diabetes*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Cancer / tumors*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Back / joint problems*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

High blood pressure*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Thyroid problems*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Recurrent or chronic infectious disease*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Mental Health History

Have you ever been hospitalized? If yes, list the reason(s)

Will you be bringing any medications on your CFHI Program? If yes, please list all medications you will take with you on your CFHI Program:

Please list all medications you will take with you on your CFHI Program

Please list any allergies to food or medicine (describe reaction if known)

Are you currently pregnant*

Yes

N/A

If yes, what is your expected date of delivery?*

Have you ever been treated by a psychologist, psychiatrist or counselor for any mental, emotional or nervous disorder?*

Yes

MENTAL HEALTH HISTORY (Have you ever suffered from, been treated for, or hospitalized for the following?)

Any mental health condition, such as depression / anxiety*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Substance abuse (alcohol or drugs)*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Eating disorders: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Anxiety disorders: Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, specific phobias*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Mood disorders: Depression, Bipolar Disorder, and Cyclothymic Disorder.*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Psychotic disorders: Schizophrenia*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Impulse control and addiction disorders:. Alcohol Abuse, Drug Abuse, Pyromania (starting fires), Kleptomania (stealing), compulsive gambling.*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Personality disorders: Antisocial Personality Disorder, Obsessive-compulsive Personality Disorder, and Paranoid Personality Disorder, Borderline Personality Disorder*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Obsessive-compulsive disorder (OCD)*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Post-traumatic stress disorder (PTSD)*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Dissociative disorders: Multiple Personality Disorder, Depersonalization Disorder*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Factitious disorder*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Somatic symptom disorders*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Tic disorders: Tourette's syndrome*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Other conditions such as sleep related problems*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

Are you taking / have ever taken medication for above problems?*

Yes – in the last year

Yes – in the last 2 years

Yes – in the last 5 years

Yes – more than 5 years ago

If you selected any of the above conditions, when did you experience this condition, and when were you diagnosed? Please list specific dates.

How was this condition treated and for how long? Include dates and type of treatment, name and dosage of medication(s) etc.

Are you currently receiving any treatment (clinical or pharmacological) for your mental health condition? If yes, please describe below:

Describe any triggers that might lead to the recurrence of symptoms.

CFHI is committed to providing all participants equal access to its educational opportunities and programs. Please provide a detailed description of any academic accommodation(s) you are requesting.

Is there anything else you would like CFHI to know about your identity or health that you believe will help contribute to your health, safety, and wellbeing during your CFHI program? Thank you for sharing.

If relevant to you, please indicate if you prefer person-first (e.g. people with disabilities) or identity-first (e.g. disabled people) language

Signature*

Sign here to certify that all responses made on this form are complete, true, and accurate. I understand that if my health status differs from what is described on this form, I will promptly contact CFHI to inform them. I understand that changes in my health status could require CFHI to alter certain program components, such as lodging, provide me with additional on-site support or, in rare cases, terminate my participation in the program.

Health History Form

Psychological/Mental Health History

PHYSICAL HEALTH HISTORY

Mental Health History

MENTAL HEALTH HISTORY (Have you ever suffered from, been treated for, or hospitalized for the following?)

CFHI is an NGO in Special Consultative Status with the ECOSOC of the United Nations

Find Your CFHI Opportunity and
Let the World Change You!

Enquire now

Psychological/Mental Health History

PHYSICAL HEALTH HISTORY

Mental Health History

MENTAL HEALTH HISTORY (Have you ever suffered from, been treated for, or hospitalized for the following?)

CFHI is an NGO in Special Consultative Status with the ECOSOC of the United Nations

Find Your CFHI Opportunity and Let the World Change You!

Enquire now

Find Your CFHI Opportunity and
Let the World Change You!