Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697742077082.pdf (Georgia)
MEDICAL SELF ASSESSMENT Please fill in this form.

It is a declaration on the state of your health.

If the medical examination results disqualify you from participating in Teach and Learn with Georgia, all costs for entry, stay, and departure will be borne by you.

You need to scan + email this form to TLG/Recruiting Agency along with other application documents.

ATTENTION!
ATTENTION!

If you answer YES to any question except #8, you must attach a letter with detailed explanation of your health condition, its causes, any medicine used for treatment and the success of your recovery.

This information will be taken into consideration to provide you with additional/special care or offer other living conditions suitable to your health.

AGE GENDER HEIGHT IN CENTIMETERS cm WEIGHT IN KILOGRAMS kg QUESTION YES NO IF YES, PLEASE EXPLAIN (1) Are you HIV or AIDS Positive?
(2) Have you ever had or do you have any skin disease?

(3) Have you ever had an infectious disease that poses a risk to public health (including, but not limited to, tuberculosis, malaria, cholera or any STD)?

(4) Have you ever had any of the following: 1.

Allergies 2.

High blood pressure 3.

Diabetes?

4.

Any type of Hepatitis?

(5) Have you ever suffered from, or been treated for, depression, anxiety, or any other mental or mood disorder (bipolar, schizophrenia etc)?
(If you have received treatment, please explain and attach an official medical report).

(6) Have you ever been addicted to alcohol?

(7) Have you ever abused any narcotic, stimulant, hallucinogenic or other substance (whether legal or prohibited)?

(8) If necessary, are you prepared to undergo physical tests to verify the answers given in questions ① through (7)above?

(9) Have you been hospitalized in the last two (2) years?
(10) Have you had any serious injury, ailment or sickness in the last five (5) years?

(11) Do you have any visual or hearing impairments (excluding those that are easily corrected with glasses or contacts)?

(12) Do you have any physical disabilities?

* (13) Do you have any cognitive/mental disabilities?

(14) Are you taking any prescribed medication?

(15) Are you on a special diet?

(16) When and for what reason did you last consult a physician?
Date: MM/YYYY Reason: (17) On average, how many standard servings of alcohol do you consume each week?

The answers I have provided throughout this application are true and correct to the best of my knowledge and I will bear full legal and financial responsibility for any errors or falsehoods contained herein.

I am aware that any violation of TLG policies even prior to arriving in Georgia can result in termination of the TLG Contract.
FIRST NAME MIDDLE INITIAL LAST NAME MM / DD / YYYY SIGNATURE (must be in ink after being printed) DATE *Physical disability  A physical disability is any impairment which limits the physical function of one or more limbs or fine or gross motor ability.
Other physical disabilities include impairments which limit other facets of daily living, such as respiratory disorders and epilepsy  The condition of being unable to perform as a consequence of physical or mental unfitness   Means being "different" than the crowd.

Incapacity to function normally, caused by a bodily defect or injury.
If you answered "Yes" to any question other than question #8 or listed a current or past medical condition in the Self Assessment above other than a common cold or hay fever, please: 1) Provide a brief explanation about your medical condition, causes, medicine used, and its status today or success of your recovery.
2) Be informed that you might be asked for a doctor's note about this medical condition, its origins, treatment, and, most importantly, its medical status today 3) If you take any medication, outline a brief plan of how you are going to supply yourself with enough medicine while in Georgia.

If you do not take medication, this step does not apply to you.
4) Sign the following medical statements: I understand that if any medical condition stated in my self assessment form occurs or any pre-existing health condition (chronic diseases) gets worse, and if I have to visit a doctor about it while I am in Georgia, the TLG insurance will not be covering me.

I also understand potential seriousness of allergies (any kind of allergy, Seasonal e.c.)

I know that allergies are considered as a pre-condition and this will not be covered by Insurance in Georgia.
I promise to tell every doctor or medical worker I will visit in Georgia about my allergy to _________________________________ and to warn them against giving me treatment with it.

I understand that if further medical treatment is required for these pre-conditions, TLG has the right to terminate my contract and I am bound by the TLG contract to pay the cost of my ticket out of Georgia and to reimburse TLG for the cost of the ticket that brought me there.
Name __________________________________________________ Signature __________________________________________________ Date __________________________________________________