MISSIONARI VERBITI-Via Dei Laghi Bis,52 00040 Nemi(Roma) ITALIA

CENTRO AD GENTES

MISSIONARI VERBITI-Via dei Laghi bis,52 – 00040 Nemi(Roma) ITALIA

Website: adgentes.net > Phone: (+39) 06-9365 0001 > e-mail:

MEDICAL RECOMMENDATION FORM

(Application for the SVD International Renewal Program)

TO THE EXAMINING PHYSICIAN:

We ask you to please supply the information requested for the necessary care and attention during the program. The person presenting this document is asking to participate in an international renewal program to be held in Europe. The program requires distant travel, climate change,food adaptation, pilgrimages and visits with some strenuous walking and occasional climbing.

Gratefully yours,

Fr. Tony Bon Pates, SVD

Director - SVD International Renewal Program

THE APPLICANT

Complete Name:

Age:

Height:

Weight:

Blood pressure: Blood Type:

GENERAL HEALTH CONDITION

1. Significant impairment or disability (sight, hearing, walking …):

2. Any health conditions requiring periodic supervision of a physician while taking the program.

3. Any medical prescription (for example diabetes, hypertension, arthritis, gout, rheumatism etc).

4. Does the applicant need any special diet?

5. Is the applicant allergic to any medication? Pleasespecify?

6. Has the person received any treatment for any health problem, alcoholism etc?

GENERAL HEART CONDITION

1. If there is any heart or other history suggesting limits for physical exercise, please indicate.

2. Is the applicant taking any maintenance medication?

3. Is the person presently under any supervision for heart problem?

Check as appropriate:

/__/ I have given the applicant a thorough medical examination and in my clinical judgment this person is fit to participate in the program and to take some strenuous walking and occasional climbing.

/__/ Although I endorse, this applicant’s participation in the program, certain limitations(s) should be placed on this person’s physical activities (work, hikes, athletics, etc…)

/__/ I do not feel the applicant’s health would permit him to attend this international program.

Place / Country: Date:

Signed by the Attending Physician