Confidential Health Form – Guayaquil 2024

Confidential Health Form for Alliance for Smiles mission to Guayaquil, Ecuador from June 16 to 22, 2024

Your Name (required)

Your Email (required)

Birthdate (required)

Gender

A medical mission can be a stressful event for a healthy body and it can be risky for those with medical or psychological health conditions that are not managed properly before departure. It is not uncommon for a condition that was under control at home to flare up while on a mission.
Volunteers with known and ongoing medical problems, such as allergies or diabetes, must take special precautions in preparing for and managing their situation. You need to anticipate how your new environment and the stresses of a mission in a foreign country can impact your health. There may be fewer resources in foreign settings to help you deal with health problems. For example, a volunteer with allergies needs to ensure that specialized medications will be available, and someone with diabetic needs to consider the consequences of contracting malaria.
Volunteers Using Medication: If you use medication on a regular basis, you should take a supply to last throughout your stay and carry a letter from your physician explaining the medical necessity and treatment.
Travel Insurance: Alliance for Smiles (or Rotary International) provides travel medical insurance for all team members. All team members must be covered under this insurance policy, regardless of whether you have your own insurance policy.

GENERAL HEALTH (required)
Please describe your current health status, including any issues which may affect your ability to perform on a medical mission:

ALLERGIES
Please list any allergies you have:

MEDICATIONS
Please list any medications you are currently taking:

COVID-19

AfS requires all volunteers to be vaccinated against COVID-19. You are considered fully vaccinated against COVID-19 two weeks (14 days) after your dose of an accepted single-dose vaccine or two weeks (14 days) after your second dose of an accepted 2-dose series.

Covid Vaccine:

Date Dose 1 (required):

Date Dose 2 (if applicable):

EMERGENCY CONTACT # 1:

Name:

Contact Info:

EMERGENCY CONTACT # 2:

Name:

Contact Info:

IN CASE OF DEATH
Please perform the following actions in case of my accidental death:

Today's Date (required)

By clicking SUBMIT, I certify that all of the above information is accurate, true and complete to the best of my knowledge. I also consent to any necessary examination, anesthetic, medical diagnosis, surgery, treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip identified above.