Personal Information

First Name*

Last Name*

Nickname (optional)

School*

Email*

Phone*

Because study abroad can be quite rigorous and demanding, we believe that only those students who are in good physical and mental health should plan to participate. For that reason we ask that the student carefully read and agree to the following. By checking the box below I certify that I am in good physical and mental health and that I do not suffer from any special mental or physical problem or condition that would prevent me from successfully taking part in the study abroad program in Thailand. I further understand that, in the event of an emergency abroad, the Program reserves the right to notify my parent(s) or guardian.

Health Agreement

Yes, I agree

Medical History

Height*

Weight*

Resting heart rate*

Blood pressure if known (if unknown write "unknown"*

Do you currently have or have a history of the following:

Respiratory problems? Asthma?*

Yes
No

If you answered yes, please explain.

Gastrointestinal disturbances?*

Yes
No

If you answered "Yes" please explain, including any medications you might take to treat the problem.

Diabetes?*

Yes
No

If you have diabetes, please provide more details including if you inject insulin, or use an insulin pump, etc.

Bleeding or blood disorders?*

Yes
No

If you have a bleeding or blood disorder please explain, including diagnosis and/or ongoing treatment/management.

Hepatitis or other liver disease?*

Yes
No

If "yes" please explain including diagnosis and treatment or management plan.

Neurological problems?*

Yes
No

Please explain the diagnosis and treatment plan.

Seizures?*

Yes
No

If yes, please describe your diagnosis, treatment/management plan, any triggers, etc.

Dizziness/vertigo or fainting episodes?*

Yes
No

If yes, please provide details of your diagnosis and treatment/management plan.

Migraines?*

Yes
No

If yes, please describe how frequent, treatment, and are they debilitating?

Disorders of the urinary or reproductive tract?*

Yes
No

If yes, please describe, including diagnosis and treatment/management plan

High blood pressure?*

Yes
No

If yes, please describe including treatment / management plan, including medication if any.

Fainting, blackouts?*

Yes
No

If yes, please describe, including any diagnosis and triggers.

Hepatitis, HIV or AIDS related condition?*

Yes
No

If yes, please describe, including your diagnosis and any medications (ARVs, etc.).

Physical disabilities (vision, hearing, mobility, etc.)*

Yes
No

Please describe including your management plan and any required accommodations

Do you have any history of cardiac illness or significant risk factors, such as known coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, tachyarrhythmia, symptomatic bradycardia (syncope, dizziness), unexplained chest pain (especially with exercise), or immediate family history of early cardiac death (<50 years old)?*

Yes
No

If yes, please explain.

In the past three years, have you had any knee, hip, ankle, leg or foot injuries (including sprains, dislocations) and/or surgery?*

Yes
No

If yes, please explain, including if there are any on-going pain or mobility issues.

In the past three years, have you had any arm, elbow or back injuries (including sprains, dislocations) and/or surgery?*

Yes
No

If yes, please explain, including if there are any on-going pain or mobility issues.

Have you had a significant blow to the head leading to loss of consciousness or concussion?*

Yes
No

If yes, please describe, including how long ago and if there are any on-going issues/symptoms

Have you had Covid-19?*

Yes
No

If yes, how many times? If no, enter "0".*

Do you have Long Covid symptoms (cognitive impairment, fatigue, etc.)? Please describe. If no symptoms of Long Covid, write "None."*

Other serious illness, injury, operation or condition?*

Yes
No

If yes, please explain.

Have you been hospitalized in the last 5 years?*

Yes
No

If you answered "yes" please describe, and note if there are any ongoing issues or not.

Are you pregnant?*

Yes
No

Do you plan to take any prescription or non-prescription medications while on the program?*

Yes
No

If yes, please describe, including the diagnosis / condition the medication is for, and if you can bring enough with you for the duration of your program.

Mental/Emotional Health

Applicants with a history of mental or emotional health issues within the past three years, which may have required psychotherapy, medication, hospitalization or residential treatment, need to be in a period of stability ranging from six months to two years, depending on the condition, to participate in the program. ISDSI programs are not appropriate for applicants just leaving residential treatment facilities. Depending on your specific mental/emotional health issues we may require a letter from a health professional as to your ability to participate on your program.

While we do have student mental/emotional support professionals on staff, we are unable to provide any intensive counseling, treatment or extended support for mental health or behavioral issues.

Have you been diagnosed with a mental / emotional health condition?*

Yes
No

If yes, please describe your diagnosis, if it was in the past or is on-going, and your treatment plan.

Are you currently engaged in counseling / psychotherapy?*

Yes
No

If yes, please explain, including your treatment plan while on the program.

Are you taking any medications for emotional / mental health?*

Yes
No

If yes, please describe, including if you will be able to bring enough medication for the duration of your program.

Please indicate any of the following that have been present in the last three years:*

If you checked any of the above conditions or symptoms please explain below.

Do you have any other mental or emotional health issues or diagnosis not covered above?*

Yes
No

If yes, please describe your diagnosis and any medication or treatment plan.

Do you have any physical, cognitive, or sensory condition that would require consideration?*

Yes
No

If yes, please describe your condition and any required accommodations.

Immunizations

Due to remote travel, exposure to vulnerable communities, as well as Thai public health recommendations, students on ISDSI programs are required to be fully vaccinated with all CDC required childhood and other vaccinations. ISDSI also requires vaccination against COVID-19/SARS2 due to both Thai public health and local community requirements.

Covid-19?*

Yes
No

If yes, when was your last booster? Thailand requires a booster within the last year.

Chickenpox (Varicella)*

Yes
No

Hepatitis A*

Yes
No

Hepatitis B*

Yes
No

Human Papilloma Virus (HPV)*

Yes
No

Influenza*

Yes
No

Measles, mumps, Rubella (MMR)*

Yes
No

Meningococcal*

Yes
No

Pneumococcal*

Yes
No

Polio*

Yes
No

Tetanus, diphtheria, pertussis*

Yes
No

If you answered "No" to any of the above vaccinations, please explain. Otherwise type "All" in the field below.*

Allergies

Regardless of the allergen, individuals with a history of severe allergic (anaphylactic) reactions are required to bring a personal supply of epinephrine, preferably in a pre-loaded auto-injector, and know how to use it.

Are you allergic to or have a medically related intolerance to any food?*

Yes
No

If yes, please describe the allergen and your reaction to exposure, as well as your treatment plan.

Have you had an allergic reaction to insect bites, bee or wasp stings, or medications resulting in hives, swelling of face/lips or difficulty breathing?

Yes
No

If yes, please describe the allergen (insect or medication) and your reaction to exposure, as well as your treatment plan.

Do you have any other allergies?*

Yes
No

If yes, please describe the allergen and your reaction to exposure, as well as your treatment plan.

Asthma, Heat & Fitness

Do you have asthma?*

Yes
No

If yes, please describe any triggers to your asthma, as well as treatment (inhaler, etc.).

Do you have a history of heat stroke or other heat related illness?*

Yes
No

If yes, please describe, including how long ago, diagnosis, and any on-going issues.

Do you exercise regularly?*

Yes
No

Do you smoke, vape, or use tobacco products?*

Yes
No

Please note that vapes are currently illegal in Thailand, and smoking is not culturally acceptable in many villages.

Can you swim?*

Yes
No

Learning Accommodations

Do you have any learning accomodations?*

Yes
No

If yes, please describe below. ISDSI will follow up with an accommodations form for you to fill out as well.

Dietary preferences

The emphasis at ISDSI is on eating locally and respecting the local “foodshed” and host cultures. While on your own, you can of course choose your own food. However, while in villages or homes you will need to be flexible and respectful of Thai culture. While there is some flexibility in an urban settings, in rural areas while living with villagers it is impossible to follow a strict vegetarian or vegan diet, or other food preferences. As a part of respecting cultures that are different, students need to be flexible and understand not everyone has the privilege to have food preferences.

Do you have any religious based food prohibitions (kosher, halal, etc.)?*

Yes
No

If yes, please describe including any food restrictions.

Do you follow a specific diet? Please check all that apply.*

Please describe any other dietary restrictions you might have?

Recognizing that in poor and marginalized communities students may not have the food choices they prefer, are you willing to be flexible?

Yes
No

Emergency Contact Information

Emergency contact name*

Emergency contact relationship to you*

Emergency contact cell / mobile phone number*

Emergency contact email*

Do you authorize ISDSI to contact your emergency contact and share medical information in an emergency?*

Yes
No

Signature

By my signature on this form I confirm that the information provided on this form is an accurate and complete record of my health history, and that failure to disclose information could result in harm to self and other participants. I also agree to disclose any changes in your health status prior to the start of your program. I also confirm that on the basis of the program description and other information about the program, and what I know or suspect about my physical, emotional, and mental health, that this program is appropriate for me and I can participate fully in the course.

By entering my name here and submitting this medical disclosure form, I certify that all of the information in this application is true, correct and complete:

Digital Signature*

ISDSI

Required Health Information for ISDSI Programs

Please fill out and digitally sign the following health information form. This information is required for participation in all ISDSI programs.