Staff Confidential Health Form

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If you have been asked to provide a medical assessment for someone who wants to join us as staff please fill in the form below. To reduce the chances of data theft we have NOT included the option to save your form, so it must be completed in one sitting. If you have any questions you would like answered before completing it please contact us at info-fj@marinereach.com.

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• Marine Reach is a ministry of Youth With A Mission (YWAM). YWAM is an international, interdenominational missionary organization, which began in 1960 and now has hundreds of bases operating worldwide. Marine Reach seeks to serve the isolated communities around the world by providing free medical care as expressions of God‟s love and mercy. As a ministry, Marine Reach aims to mobilize teams and resources into remote areas and coastal villages by using small ships, medical trucks, containers and clinics as a practical demonstration of God‟s heart for those living in poverty and need.
  
  The applicant you are assessing has applied as a staff member for Marine Reach Ministries and this will involve mission work in an unfamiliar environment. Thank you for your willingness to help in this process.
  
  The position they have applied for could involve stressful conditions, but will provide an opportunity for them to use their skills. Please be as concise and thorough as reasonably possible as certain conditions such as diabetes, epilepsy, heart disease and obesity may affect their acceptance as staff. Ensure any pertinent information in this area has been included.

• Applicant Information

• Name of Applicant*
  First Last
• Applicant's Current Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
• How long has the Patient attended your Practice (in years and months)?
  Years Months

• Physician Information

• Name of Physician*
  First Last
• Practice Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
• Practice Phone Number*
• Practice Email
  If you provide an email address a copy of this form will be sent to you on completion

• Examination

• Height*
• Weight*
• Blood Pressure*
• Pulse*
• Blood Group*
• Rh Factor*
• Urinalysis*
  Glucose, Protein, Blood

• Are there any abnormalities in the following systems?

• ENT*
  • Yes
  • No
• Please Explain Fully
• Ophthalmalogical*
  • Yes
  • No
• Please Explain Fully
• Dental*
  • Yes
  • No
• Please Explain Fully
• Neurological*
  • Yes
  • No
• Please Explain Fully
• Cardiovascular*
  • Yes
  • No
• Please Explain Fully
• Respiratory*
  • Yes
  • No
• Please Explain Fully
• Musculoskeletal*
  • Yes
  • No
• Please Explain Fully
• Endocrine*
  • Yes
  • No
• Please Explain Fully
• Lymphatic*
  • Yes
  • No
• Please Explain Fully
• Dermatological*
  • Yes
  • No
• Please Explain Fully
• Hernial Orifices*
  • Yes
  • No
• Please Explain Fully
• Genito-Urinary*
  • Yes
  • No
• Please Explain Fully
• Psychiatric*
  • Yes
  • No
• Please Explain Fully
• Gastro-Intestinal*
  • Yes
  • No
• Please Explain Fully
• Recommendations for Follow-Up Tests/Treatment/X-Ray/ECG if indicated

• Assessment Summary

• Physician's Recommendation
  • Acceptable Without Limitation
  • Acceptable With Limitations (please specify)
  • Should Remain Where Adequate Medical Care Is Provided
  • Not Acceptable
• Details
• Thank you for completing this form. Please click the Submit button once you are satisfied that you have answered all of the relevant questions appropriately.
• Please confirm you are a genuine user by typing the characters in the image
• Phone
  This field is for validation purposes and should be left unchanged.

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