University of Missouri-Columbia …

        University of Missouri-Columbia                              N52 Memorial Union
        The International Center                                     Columbia, MO 65211
                                                                     PHONE (573) 882-6007
        Study Abroad                                                 FAX (573) 882-3223
                                                                     E-MAIL StudyAbroad@missouri.edu
                                                                     WEB http://international.missouri.edu




                              HEALTH INFORMATION
The purpose of this form is to enable the International Center to obtain
information regarding facilities which are available overseas for students who
have specific health concerns. The information provided on this form will be
forwarded to the appropriate overseas contact person in an effort to make any
arrangements that might be necessary, and will be released to an attending
health processional in the event of an illness or medical emergency. The
disclosure of medical information will not affect your admission status.

1. List any serious illnesses, operations or injuries that you feel could affect your health while
   abroad:
                                                                               Dates:




2. List any allergies that you have, including hay fever, asthma, or food allergies:




3. Do you have a disability or any other condition that might require special accommodations?
   If yes, please explain the types of services that you would like us to try to locate overseas:




                                               (over)
4. Are you currently seeing a counselor or other medical professional for emotional or
   psychological problems that will require on-going treatment while you are overseas? If yes,
   please indicate the type of health care, which you would like us to try to locate at your
   program site:




5. Is there a chance that your participation in full-time academic activities will be limited in any
   way due to a health reason? If so, please explain.




6. Please list below any prescription medications that you are currently taking, including the
   dosage and the condition that the medication was prescribed to treat. This information will be
   made available to health care professionals overseas in the event of a medical emergency.
   Please note that in some countries it is not possible to fill prescriptions written in the U.S. or
   to receive medications through the mail. Please check with your overseas studies advisor on
   the specific regulations that may exist in your host country.




7. Is there any other medical information that you would like to provide?




I understand that this information will be released to the appropriate overseas contact
person who is granted permission to use it when, in his or her best judgment, health
conditions so warrant.

Student Name:                                                      Student Number:

Term(s):

Program Sponsor:
(e.g. International Center, Business, CAFNR, HES, Journalism)


Student Signature:                                                 Date: