ROTARY AUSTRALIA WORLD COMMUNITY SERVICE LIMITED

ACN 003 444 264       ABN 37 739 341 003 
   

HEALTH FORM FOR PROJECT VOLUNTEERS (F.A.I.M/I.P.A.C./S.W.S.L.)
 

ACTIVITY....................................................REGION............................................................

PROJECT..................................................LOCATION.........................................................

Brief description of work and travel.......................................................................................

.................................................................................................................................................

.................................................................................................................................................

Dear.........................................................................Date.......................................................

Thank you for your offer to help in the above project. As projects may be located in isolated areas, it is important that you have no significant existing health problems.

Would you please complete the health statement and ask your usual medical practitioner to complete the statement in the space provided on the back of this page.

Regards,

................................................... (Project Co-ordinator)
   

PERSONAL HEALTH STATEMENT

By signing this document below I honestly declare that:

I am currently fit to participate as a F.A.I.M./I.P.A.C./S.W.S.L. volunteer and do not suffer from any illness, ailment or incapacity that may prevent me completing my volunteer duties.

I realise that the project for which I am a volunteer, may be located in isolated areas, and communications may be non-existent.

I realise that transport back to base may only be available at pre-arranged times, i.e., end of project. Also, I realise there is a risk of getting malaria, even if right preventative measures are followed.

Please indicate if you have, or have had, any of the following health problems.

Answer YES or NO  

Previous surgical operations....................................................................................................

Medications taken at present...................................................................................................

Special dietary requirements...................................................................................................

Any further comments............................................................................................................

................................................................................... Date..............................

Volunteer's signature  

MEDICAL REPORT:

Dear Doctor,

Your patient has volunteered to work for a Rotary Overseas Aid Project, in a non-paid capacity, for a period of.......................days / weeks.

These projects may be located in very isolated areas and a walk of some hours in hilly, tropical jungle may be necessary. Also some hard work will be involved.

Communications may be non-existent and transport back to base may only be available at pre-arranged times, i.e., at the end of the project.

In spite of preventative measures, malaria may be contracted.

Would you please give your professional consideration on your patient's health?

REPORT:

Age ................. Height ................ Weight.............. Blood pressure..............

Has your patient ever suffered from:  

Has your patient had any disease, impairment, or abnormality of:  

If YES to any of above, please give details:

......................................................................................................................................

Please list previous surgical operations:............................................................................

......................................................................................................................................

Current medications:.......................................................................................................

......................................................................................................................................

On consideration of the above, do you consider the volunteer physically well enough to cope with this project? YES / NO

Other comments.............................................................................................................

Medical Practitioner's signature........................................................................................

NAME.............................................................................................................................

ADDRESS.......................................................................................................................

PHONE...................................................................DATE...............................................