Dietary & Medical Form | The Chinese Language Institute

Participant Information

Name

First

Last

Date of Birth

Email

Program Name

Dietary Information

Food Allergies

(if none, enter N/A)

Additional Dietary Comments

Medical Information

Current Prescription Medications

(if none, enter N/A)

Drug Allergies

(if none, enter N/A)

Medical Conditions (including Mental Health)

(if none, enter N/A)

Name of Primary Care Physician

(if none, enter N/A)

Phone Number of Primary Care Physician

(if none, enter N/A)

Email of Primary Care Physician

(if none, enter N/A)

Additional Medical Comments

Pre-existing Medical Conditions

Please answer Yes/No to the following. In the past 3 years, have you experienced:

Joint injuries

Yes
No

Circulatory problems

Yes
No

High blood pressure or heart disease

Yes
No

Anxiety disorder

Yes
No

Clinical depression

Yes
No

Muscular injuries

Yes
No

Seizures

Yes
No

Asthma

Yes
No

Broken bones

Yes
No

Migraines

Yes
No

Additional Comments

Electronic Signature of Participant

I declare that:

My information as entered above is accurate and correct to the best of my knowledge.
I authorize CLI to share the above self-reported medical and health information with my upcoming study abroad program's faculty leader, relevant administrators, and necessary destination-country personnel.

Dietary & Medical Information

Participant Information

Dietary Information

Medical Information

Pre-existing Medical Conditions

Electronic Signature of Participant