Medical Questionnaire Volunteers

Medical Questionnaire - Change Volunteers

Complete this information completely and honestly. This information will be kept very confidential.
This part of the application will require some sensitive information. We understand that a person's past can be a very tender subject to discuss possibly due to past painful experiences. However, we know that when you honestly and completely answer all the questions that apply, you will provide us with information that we can use to most effectively help you. This information will be treated most confidentially. We make sure that only staff of the same gender will read this portion of your application. Again, the only purpose for probing these areas is to provide help, support, and sensitivity that will lead to healing and wholeness if you are struggling in any of these areas. Any past problem in an area doesn't necessarily exclude you from our trips. Our goal is healing (when necessary) not exclusion or judgment.
Confidential Medical and Psychological Questionnaire
Names*

First NameLast Name
E-mail*
Confirm e-mail*
Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
How many days were you absent from work (or school) due to illness in the last year?*
Are you currently taking any medications or under a doctor's care?*

YesNo
If yes, indicate the reason, medication, purpose and any limitations it may cause*
Have you been hospitalized in the past 5 years?*

No, I have not been hospitalized in the last five years.Yes, I have been hospitalized in the last five years.Option 3
If you've been hospitalized list each incidence, the number of days or weeks or months you spent in the hospital and why you were admitted or treated:*
Check all that apply. This will be kept very confidentially.*

I have a chronic illness or allergiesI have been convicted of a felonyI have had episodes of rebellion in my life in the last two years (defiance of authoritty figures, not open to acountability, defiance to laws, etc)I have used illicit drugs such as narcotics, hallucinogens and or / drugs not prescribed by a physician in the last two yearsI currently drink alcoholic beveragesI currently use tobacco productsI have been treated for a drug or alcohol problemI tend to experience strong anxietyI have struggled with cutting, panic attacks, and /or attempted suicideI have had prolonged problems with depression or mood swingsI have struggled with an eating disorder (anorexia, bulimia, or overeating)I have consulted a physician/psychiatrist/psychologist concerning a mental or emotional conditionI have been physically abused, sexually abused, and /or rapedI have hurt someone physically or sexually AND still struggle with that pastI have not used tobacco products in the last 2 yearsI have not drank any alcohol in the last two yearsI have been in the gangI have handicaps or health conditions that require special careI do not have any of the aboveI have other struggles that I believe are significant (write below)
Other Significant Struggles:
Are you willing to abstain from the consumption of alcohol and tobacco during the duration of your volunteer trip with us? It doesn't matter whether you currently smoke or not. This question is asking if you will stay away from these things while in the program (you will not start them if you don't already use them or continue them if you currently do)*

YesNo
Self Awareness: Please check the 3 areas you struggle with the most: (We all struggle with something. Indicate yours)*

ComparisonDepressionHatredGluttonyPassivityInsecurity / low self-worthGreedUnforgivenessSelf-justificationMaterialismEnvy / JealousyAngerAnxietyRebellionPrideControlManipulationCoarse jokingLyingCo-dependencyIdolatryFearLustLying
Do you have any additional comments or clarifications about anything on this questionnaire?

EMMERGENCY CONTACT
Emergency Contact
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home phone*

Area CodePhone Number
Work phone

Area CodePhone Number
Email*
Confirm Email*
Should be Empty:

Medical Questionnaire - Change Volunteers

Confidential Medical and Psychological Questionnaire

Emergency Contact