Student Information

Name of Student: ......

Passport Number: ......

Health and Safety Questionnaire

The purpose of this form is to help us be of maximum assistance to you during your study abroad experience. Mild physical or psychological disorders can become serious under the stresses of life while studying abroad. It is important that we are made aware of any medical or emotional problems, past or current, which might affect you in a foreign study context. The information provided will remain confidential and will be shared with appropriate professionals only if pertinent to your own well-being. We may not be able to accommodate all individual needs or circumstances.

Medical History

1. Are you generally in good physical condition? (If no, please explain below). YES/NO

2. Have you ever been treated or are you currently being treated for any psychological or emotional problems? (If yes, please explain below). YES/NO

3. Do you have any allergies to drugs or food? (If yes, please explain below). YES/NO

4. Are you taking any medications? (If yes, please explain below). YES/NO

5. Have you had any major injuries, diseases or ailments in the past five years? (If yes please explain below). YES/NO

Explanation Medical Treatment Release

Although student understands that, whenever possible, advance consent of student or student’s spouse or family will be sought for necessary emergency treatment, student agrees that medical, psychiatric treatment or surgery may be performed in the event student is incapacitated or otherwise unable to provide consent to such treatment and, in the opinion of competent medical authorities, the health or welfare of student will be adversely affected by any delay. Student hereby agrees to grant permission for necessary medical treatment during participation in the programme.

Declaration

I certify that I am ...... I certify that all responses made on this form are accurate to the best of my knowledge. I have read and agree to the conditions specified in this form and will notify the programme advisors at Brighton any changes in my health that occur prior to the start of the programme. I further understand that, in the event of an emergency abroad, the Brighton advisors reserve the right to notify my parent(s) or guardian.