Lehigh University
Study Abroad Faculty-Led Programs

Health Information Form
General and Emergency Contact Information
Please note: Disclosure of the following information is voluntary. However, it is in the best interestof each program participant to disclose any physical, psychological or other medical condition thatmay affect their health, wellness or safety during the trip abroad. This information allows us toidentify and discuss your needs, as well as provide optimal care to participants if the need arises.
Confidential physical health and mental health counseling is available at the Health and Wellness
Center (ext. 3870) and at Counseling and Psychological Services (ext. 3880).

Name: _______________________________ Lehigh Student ID: _______________Country of Study/Service: ________________________
Emergency Contact:
Name: ___________________________ Relationship: ___________________
Home Tel.: __________________ Bus. Tel.: _________________ Cell: _____________
Email address: _Name: ___________________________ Relationship: _________________________
Home Tel.: __________________ Bus. Tel.: _________________ Cell: _____________
Email address: _I Decline to Disclose the Following Information.
Health/Psychological Care Professional Contact Information:
Name: ________________________________________________________________
Address: _______________________________________________________________
City: ________________________________ State: _____________ Zip: ___________
Telephone: ________________________ Fax: ________________________________
Clinical History
Are you currently under medical treatment? __ yes __ no
Do you have a chronic medical condition (asthma, diabetes, IBS, Crohn‟s, etc.)?
__ yes __ no If „yes‟ please identify the condition(s) below:__________________________________________________________________________________________________________________________________________________________________________________________________________________Have you had any psychological, psychiatric, or personal issues (including eating
disorders, substance abuse, family concerns) during the past five (5) years for which you
have sought professional services? __ yes __ noIf yes, please describe the circumstances:__________________________________________________________________________________________________________________________________________________________________________________________________________________Are you currently taking any medications? __ yes __ no If yes, please list name, dosage,
prescribing clinician and, if not listed above, contact information for that clinician.

NOTE: Please list all medications you take regularly, including those treating physical conditions(including any allergies) and psychological conditions (including depression, anxiety, or otherpsychological/emotional issue).

Name of medication
DosagePrescribing Clinician___________________ _________ _________________________________________________ _________ _________________________________________________ _________ _________________________________________________ _________ _________________________________________________ _________ ______________________________
What condition(s) is (are) being treated with medication?
____________________________________________________________________________________________________________________________________________
When did you start taking these medications?
____________________________________________________________________________________________________________________________________________Have you contacted your clinician and health insurance provider to obtain a sufficient
dosage of this medication for the duration of your study abroad program?___Yes ___ No
If “no” please list date when this contact will be made: ___________________________
Please list any allergies to medication, food or other substances/conditions:____________________________________________________________________________________________________________________________________________
Please list any dietary restrictions:____________________________________________________________________________________________________________________________________________Have you had any diseases, surgical operations or significant injuries within the last five(5) years that could have an effect on your participation in this program? __ yes __ noIf yes, please explain:____________________________________________________________________________________________________________________________________________Have any surgical operations been recommended that could have an effect on yourparticipation in this program? __ yes __ no If yes, please explain:____________________________________________________________________________________________________________________________________________
Do you plan to have any surgical operations between now and your date of departure?
__ yes __ no If yes, please explain:____________________________________________________________________________________________________________________________________________Is there anything else about your health or medical history that may be a factor should
there be an emergency? __ yes __ no If yes, please explain:____________________________________________________________________________________________________________________________________________

Learning Disabilities
Do you have any conditions (including physical impairments or learning disabilities) thatmight restrict your mobility or require special facilities or accommodation while abroad?
__ yes __ noHave you discussed these issues with your program coordinator?
__ yes __ noIf „no‟, would you be willing to be contacted by your program coordinator to makearrangements to accommodate your needs while abroad? __ yes __ no
Authorization Statement
I hereby authorize Lehigh University to release information from my medical history,
including but not limited to medical records, upon the request of the program leaders.
I understand that the Faculty/TA/GA will not request any information from my medicalrecords unless a situation arises while I am a participant in the intersession trip thatmakes it necessary to have the information pertinent to my safety or health.
I further understand that any information obtained from my medical records by theFaculty-led program leadership will be destroyed upon the completion of the study
abroad program.
I understand that, if I have a medical, psychiatric or psychological condition that requiresor has required treatment, I must discuss my situation with my clinician.
I certify that the information on this Health Information Form is true and correct, and I will notify theFaculty-led program leadership hereafter of any significant or relevant changes in my health that
occur prior to or during the study abroad program.

Student‟s Signature: _____________________________________________________
Printed Name: __________________________ Date: ___________________________