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The form guides students to fill Part I with general health details, allergies, diet, medications, medical history, communicable diseases, serious health considerations, immunization dates, and any reasonable accommodation requests. 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The SDCCD Study Abroad Health Clearance Form must be signed and included  with your application, before the participant is allowed to participate in a SDCCD program. Copies of the medical history and health clearance forms are to be retained by both the healthcare professional and the participant as a confidential medical record. Complete all areas of the general health survey questions in Part Ito the best of your ability. Sign Part I and review all pages with the appropriate medical/healthcare provider(s) .  \nPART I: GENERAL HEALTH (to be completed by the student/participant) . Check or circle all items that apply.  \nLast Name:   First Name:   Birth Date (MM/DD/YY):  / /  Gender:   Student 10-Digit ID:   Program Name (list all countries you will travel) :    \nMy general health is: ☐ Excellent ☐ Good ☐ Fair ☐ Poor  \nAllergies: ☐ Penicillin ☐ Aspirin ☐ Bee stings  \n☐ Peanuts ☐ Eggs ☐ Pollen  \n☐ Other (give details)   Diet: ☐ Regular ☐ Vegetarian ☐ Restricted (give details)    \nMedications: ☐ Vitamins ☐ Birth Control ☐ Seizure Medications  \n☐ Antidepressant ☐ Inhalers ☐ Insulin injections/pump  \n☐ Other prescriptions for medical or mental health conditions (give details)    \n________________________________________________________________________________________  \nDevices: ☐ Hearing Aid- ☐ R ☐ L ☐ Contact lenses or eyeglasses  \n☐ Prosthetic joints or devices (give details)    \n☐ Other (give details)   Medical history:  \n☐ Surgery (give dates and type):  ☐ Hospitalization (give dates and type):    \nCommunicable Diseases (give dates of treatment) :  \n☐ TB   ☐ Syphilis    \n☐ HIV/AIDS   ☐ Other    \nOther serious health considerations:  \nAsthma  \nCancer/tumors  \nAnorexia/bulimia  \nHeart problems  \nHigh blood pressure  \nAlcohol or other substance abuse  \nYes  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \nNo  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \nLast Name:   First Name:    \nOther serious health considerations:  \nUlcer/stomach problem  \nBladder/kidney problem Anemia or bleeding disorder Hepatitis/jaundice  \nMigraine headaches  \nThyroid problems  \nOther    \nYes  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \nNo  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \n☐  \nMental Health Treatment: Have you been treated by a psychiatrist, psychoanalyst, psychologist, or therapist for any mental, emotional, or nervous disorder within the past year?* ☐ Yes ☐ No  \n* If yes, your mental health care provider must clear you for travel by completing Part II (Mental Health Assessment) and signing in the space labeled “signature of specialist or psychotherapist”.  \nImmunization Record: Indicate the date of your last immunization for each item. A copy of your records maybe available from your high school or health care provider. Students are advised to carry a copy of their official immunization record while traveling. An international vaccination/inoculation immunization record can be obtained from the SDCCD Student Health services center should you choose to see a travel nurse and have any such vaccinations / inoculations.  \nTyphoid (if applicable)   Meningococcal    \nPolio Immunization   Varicella/Chicken Pox    \nTetanus Booster   Hepatitis A    \nMeasles/Mumps/Rubella   Hepatitis B    \nReasonable Accommodation Request: SDCCD is committed to providing services to students with disabilities who are eligible for reasonable accommodation under the Section 504 of the Rehabilitation Act orthe Americans with Disabilities Act. If you choose not to disclose, SDCCD will not be able to assist you in arranging disability-related accommodations upon your arrival.  \nDo you anticipate requiring disability related accommodation(s) while abroad?* ☐ Yes ☐ No  \n*If yes, please attach a copy of your SDCCD Disability Support Programs and Services (DSPS) accommodation(s) letter.  ","cbCaiaMVgBIHNo34","https://ap.wps.com/l/cbCaiaMVgBIHNo34","pdf",402231,"English","# Participant Instructions\n## Part I: General Health (Student/Participant)\n## Mental Health Treatment Question\n## Immunization Record\n## Reasonable Accommodation Request\n## Student Statement and Signatures\n## Release of Information\n# Physicians / Healthcare Professionals Instructions\n## Health Screening Examination and Clearance Steps","[{\"question\":\"What is the purpose of the SDCCD Study Abroad Health Clearance Form?\",\"answer\":\"All participants must complete the form to show they are medically cleared—physically and mentally—to participate in the SDCCD Study Abroad Program. The signed form must be included with the application before participation is allowed.\"},{\"question\":\"What information must the student provide in Part I?\",\"answer\":\"Part I collects general health details, including allergies, diet, medications, devices, surgeries or hospitalization, communicable diseases, serious health considerations, and overall health status. It also includes questions about mental health treatment within the past year.\"},{\"question\":\"What should students do regarding immunization and accommodations?\",\"answer\":\"Students must indicate dates of their last immunizations and carry copies of their records while traveling. If disability-related accommodations are anticipated abroad, students should request them and attach the SDCCD DSPS accommodation letter; otherwise SDCCD cannot arrange accommodations after arrival.\"}]","SDCCD Study Abroad Health Clearance Form - Participant Instructions and Part I General Health Survey | PDF",1789565666]