Medical Forms and Information Peru

Transcription

1 2013 Medical Forms and Information Peru The Medical Forms included in this document must be completed and returned to us no later than: June 5,

2 Vaccinations & Medication The locations for STRIVE programs in Peru are all commonly visited areas and most participants do not receive additional vaccinations or medications. However all participants should discuss their own needs with their physician. The information found within the boxes on the following pages has been copied directly from the Center for Disease Control Travelers Health Peru Web page. Please visit their website at: It is entirely possible that some of the information included has recently changed and we strongly recommend that you check for the latest updates. The decisions you make regarding vaccinations for your child are entirely yours to make, after consulting with your physician. We at STRIVE are not medical professionals and are unable to offer any medical advice or recommendations. Before visiting Peru, you may need to get the following vaccinations and medications for vaccine-preventable diseases and other diseases you might be at risk for at your destination: (Note: Your doctor or health-care provider will determine what you will need, depending on factors such as your health and immunization history, areas of the country you will be visiting, and planned activities.) To have the most benefit, see a health-care provider at least 4 6 weeks before your trip to allow time for your vaccines to take effect and to start taking medicine to prevent malaria, if you need it. Even if you have less than 4 weeks before you leave, you should still see a health-care provider for needed vaccines, anti-malaria drugs and other medications and information about how to protect yourself from illness and injury while traveling. CDC recommends that you see a health-care provider who specializes in Travel Medicine. Find a travel medicine clinic near you. If you have a medical condition, you should also share your travel plans with any doctors you are currently seeing for other medical reasons. If your travel plans will take you to more than one country during a single trip, be sure to let your health-care provider know so that you can receive the appropriate vaccinations and information for all of your destinations. Long-term travelers, such as those who plan to work or study abroad, may also need additional vaccinations as required by their employer or school. Be sure your routine vaccinations are up-to-date. Check the links below to see which vaccinations adults and children should get. Routine vaccines, as they are often called, such as for influenza, chickenpox (or varicella), polio, measles/mumps/rubella (MMR), and diphtheria/pertussis/tetanus (DPT) are given at all stages of life; see the childhood and adolescent immunization schedule and routine adult immunization schedule. Routine vaccines are recommended even if you do not travel. Although childhood diseases, such as measles, rarely occur in the United States, they are still common in many parts of the world. A traveler who is not vaccinated would be at risk for infection.

3 Vaccine-Preventable Diseases Vaccine recommendations are based on the best available risk information. Please note that the level of risk for vaccine-preventable diseases can change at any time. Vaccination or DiseaseRecommendations or Requirements for Vaccine-Preventable Diseases Routine Recommended if you are not up-to-date with routine shots such as, measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, poliovirus vaccine, etc. Hepatitis A or immune globulin (IG) Recommended for all unvaccinated people traveling to or working in countries with an intermediate or high level of hepatitis A virus infection (see map) where exposure might occur through food or water. Cases of travel-related hepatitis A can also occur in travelers to developing countries with "standard" tourist itineraries, accommodations, and food consumption behaviors. Hepatitis B Recommended for all unvaccinated persons traveling to or working in countries with intermediate to high levels of endemic HBV transmission, especially those who might be exposed to blood or body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident). Typhoid Recommended for all unvaccinated people traveling to or working in Tropical South America, especially if staying with friends or relatives or visiting smaller cities, villages, or rural areas where exposure might occur through food or water.yellow Fever CDC yellow fever vaccination recommendation for travelers to Peru: For all travelers 9 months of age traveling to the areas east of the Andes Mountains and for those who intend to visit any jungle areas of the country <2,300 m (<7,546 ft). Travelers who are limiting travel to the cities of Cuzco and Machu Picchu do NOT need vaccination. Vaccination should be given 10 days before travel and at 10 year intervals if there is on-going risk. Find an authorized U.S. yellow fever vaccination clinic. Rabies Recommended for travelers spending a lot of time outdoors, especially in rural areas, involved in activities such as bicycling, camping, or hiking. Also recommended for travelers with significant occupational risks (such as veterinarians), for long-term travelers and expatriates living in areas with a significant risk of exposure, and for travelers involved in any activities that might bring them into direct contact with bats, carnivores, and other mammals. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites.

4 Malaria Areas of Peru with Malaria: All departments <2000 m (6,561 ft) including cities of Puerto Maldonado and Iquitos, except none in cities of Lima (and coast south of Lima), Ica, and Nazca. None in the highland tourist areas (Cuzco, Machu Picchu, and Lake Titicaca) and southern cities of Arequipa, Moquegua, Puno, and Tacna. During the stay in Peru your child will be in the following parts of the country: -- Lima -- Cuzco -- Machu Pichu -- Pisac which is part of the highland tourist area mentioned in the Malaria section above Doctor s Visit/Medical Forms If you haven t made an appointment for a full physical for your teen yet, please plan for this right away. The following forms must be completed in full and signed by both parents and the student s doctor. The information included on the form must be based on a recent physical which is/was completed no more than 6 months prior to your child s STRIVE departure date. Please scan and the completed forms to: Rob@strivetrips.org or make a copy to keep for your records before sending all pages of the completed forms to STRIVE: STRIVE Trips 217 West 18 th Street #164 New York, NY, 10011

5 Student Name: 2013 STRIVE TRIPS HEALTH & RELEASE FORM Gender: M/F Date of Birth: Age: Weight: Height: Address City State Zip Emergency Contact #1 Emergency Contact #2 Name: Name: Phone #: Phone #: Alt. Phone #: Alt. Phone #: HEALTH & GENERAL HISTORY General Medical History (to be completed by parents) Has the student athlete ever been hospitalized? Why? Has the student athlete ever been denied athletic participation for medical reasons? If yes, explain Protective or prescription lenses, eyeglasses, or contact lenses? Rx? Please indicate if you or any member of your family have or had the following illnesses or conditions by marking (S) for student athlete, (F) for family (sibling or parent), and (B) for both in the appropriate box. Please include dates where appropriate. Asthma Respiratory disorder Anemia (including sickle cell) Mononucleosis Diabetes Thyroid disorder Osteoporosis/Osteopenia High Blood pressure Hepatitis Heart disorder Gastrointestinal disorder Epilepsy or convulsive disorder Concussion (Number ) Frequent or severe headaches Heat stroke History of fainting or dizziness Absence of paired organ (eye, kidney) Kidney/Genitourinary disorder If Yes to any of the above, please provide additional information:

6 Student Name: Please identify any medical condition or medical history that requires special attention (use an extra page for more extensive instructions. Please provide as many specifics as possible): Immunization and Medication History and Authorization (to be completed by physician & parents) IMMUNIZATIONS ALLERGIES DRUG REACTIONS (List dates) (Yes / No) (Yes / No) Tetanus Hay Fever Sulpha Polio Asthma Penicillin Tuberculin Test Eczema Antibiotics (type) MMR Insect Stings Aspirin DPT Food Hep A Latex Other Hep B Typhoid Other Rabies Yellow Fever For any Allergies or Drug Reactions listed above, please describe the reaction and required treatment: PERMISSION TO ADMINISTER MEDICATIONS (Please write clearly ) Prescribed Medication Route Dosage Schedule *Be Specific* Comments (ALL MEDICATIONS MUST BE PACKED IN THE ORIGINAL PHARMACY CONTAINERS) We recommend that, if possible, you bring an additional valid prescription for any medications you take regularly. Please check all of the over the counter medications you allow Strive Trips personnel to provide to your child. Tylenol Tums Ibuprofen Antacid Sudefed Cough medicine Motion sickness medicine Other:

7 Student Name: Medication Authorization: The previously noted prescriptions and self carry medications are permitted for the indicated minor at all times. He/She has been instructed by the physician and parents and acknowledges a proper understanding of the purpose, frequency, and appropriate use of these items. As I consider him/her responsible, I will not hold STRIVE Trips personnel or their representatives responsible for any errors which may arise in my child s self administration of these items/medications. Physician Signature: Name: Date: Phone #: Address: Parent/Guardian Signature: Orthopedic History (to be completed by parent or guardian) Include any major musculoskeletal injury to the following areas: include sprains, dislocations, fractures, and surgery with approximate dates of injuries. Area Right Left Date Injury Type/Description Foot Ankle Lower leg Thigh Hip Spine Shoulder Upper arm Forearm Wrist Hand Head Neck Other Behavioral Health (to be completed by parent or guardian) Is the student athlete seeing a counselor? Yes/No (circle one) If yes: Psychologist/Psychiatrist Name: Address: Phone: I hereby certify that the named participant is in good health, adequately trained, and fully able to participate in all activities of STRIVE Trips. I know of no restrictions, physical impairments, behavioral issues, or any other facts, which in any manner limit his/her participation in a STRIVE Trips program. Parent/Guardian Signature: Date:

8 Student Name: HEALTH INSURANCE INFORMATION Carrier Name: Policy Number Group #: Carrier Phone #: Policy Holder Name: Policy Holder Date of Birth: HEALTH AND EMERGENCY CARE AUTHORIZATION I, the parent/guardian of, give permission for my child to be taken the nearest recommended medical facility for EMERGENCY treatment and hospitalization, if deemed necessary, and for all medical information contained herein to be shared with such facility. I understand that in an emergency, every attempt will be made to contact me, or the emergency contact specified, but that in the event I cannot be reached or means of communication are limited, a STRIVE representative will act on my behalf for treatment decisions. This STRIVE representative also has permission to disclose all medical information, as appropriate, with any involved staff, coaches or independent contractors with whom STRIVE operates. Such individuals also have permission to administer first aid to my child as needed. I will be financially responsible for any medical attention received during the program or resulting from an injury occurring during a STRIVE Trips program. My medical insurance shall be the primary insurance coverage for any medical treatment. Name of Parent/Guardian: Signed Date