Medical Clearance Form for Short-term Mission Trip
Joy Community Fellowship – Guatemala, 2019
To be filled out by team member:
Dates of anticipated trip: June 22-29/30, 2019
Name of potential trip member:
Team member’s date of birth:
Date of most recent health maintenance exam: (Must have been completed within one calendar year prior to date of departure)
Name of provider who performed exam:
To be filled out by medical examiner:
Are you aware that this individual has any allergies to medications in the class of fluoroquinolones or sulfonamides?
(One of these two antibiotic classes may be used during the trip for treatment of traveler’s diarrhea. These medications will be provided; you will not need to write a prescription for them.)
Team members must also complete the Hepatitis A series (at least one, but preferably both doses)
Dates of administration: Hep A #1: ______________ #2: _______________
Date of last tetanus booster: ______________
Hepatitis B series (required for those working in the clinic): #1:________#2:_______#3:_______
Notes to health care provider:
- Typhoid vaccine is optional, but probably not needed.
- There is NOT a need for malaria prophylaxis nor for medication to prevent altitude sickness
This trip will require the following, and EVERY team member must be able to do ALL of them:
- Plane travel of several hours time; hilly bus rides of 2-3 hours
- Lifting of objects of moderate weight, such as a full suitcase (up to 50 lbs)
- Navigating uneven, rugged and mountainous terrains, and unevenly paved city streets
- Tolerance of altitudes of up to 8,000 feet
- Fasting for over 8 hours between mealtimes, if necessary
- No qualified emergency care within 3 hours of our location
- BMI restrictions as follows: BMI > 35 may be an exclusion;
BMI > 40 is an absolute restriction to coming on this trip
By my signature below, I am indicating, to the best of my medical knowledge, that the above-named individual is in good health, and is a qualified candidate for a short-term mission trip to Guatemala, Central America on the dates of trip indicated. I am also of the medical opinion that this individual meets the physical requirements and can perform the physical duties that are listed above.
Signature of examiner: ____________________________________________ Date: ________________
(Please stamp with name of medical practice, address, and phone number.)
If there are any questions or clarification needed regarding any of the above issues, please do not hesitate to contact James Weidner, MD, (the team leader) at 856-816-3516 or at the secure email address JWeidner@advocaredoctors.com.