Alabama A&M University and Nanjing Forestry University
2016 International Research Experience in China
Alabama A&M University, Department of Biological and Environmental Sciences, Normal, AL 35762
Health Information Form
Confidential Health Information Form
Participant’s Full Name
Date of Birth (mm/dd/yyyy) Height (in inches) Weight (in lbs)
Health Insurance: All Program participants are required to carry health insurance that covers injury or
illness while traveling outside of the United States, and includes MEDICAL EVACUATION.
* See Health Insurance and Consent-to-Treat Form for details.
Do you have or have you had any disease or condition requiring medication, regular physician’s care,
surgery or other treatment? If yes, please list:
Do you take any medication(s) on a regular, on-going basis? If yes, please list:
Have you ever sought professional help for a psychiatric or emotional problem? If yes, please explain:
Do you have any of the following? If yes, please explain type and severity:
Medication Allergies NO YES
Food Allergies NO YES
Other Allergies NO YES
Asthma NO YES Require epinephrine or hospital?
Diabetes NO YES Require insulin?
Epilepsy NO YES Explain:
