Hesed/ORIGINS Medical Reference Form

Note: Medical Reference Forms will not be accepted if completed by a walk-in clinic (e.g., CVS MinuteClinic).

Your careful attention to this Medical Reference Form is vital. Your patient has applied to participate in a rigorous volunteer work program in Israel. Your medical evaluation of the applicant's physical condition and mental stability is essential in determining the applicant's suitability for the project. The applicant will be working in a large hospital and the Israeli medical system requires accurate information for the wellbeing of both the volunteer and hospital patients. This medical data will also enable medical professionals in Israel to appropriately address any medical emergencies that your patient may face during the project. If you have questions as to the medical or psychological suitability of your patient for such a project, it would be a great disservice to the patient, the volunteer group, and the hospital to approve them.
In which program will you participating?*

HesedORIGINS
Email*
example@example.com
Will you be submitting a scanned copy of your medical form or online form?*

Scanned paper copyOnline form
File Upload*

Cancelof

Name of Patient*

Patient Last NamePatient Last Name
Age*
How long has this applicant been a patient of your practice?*
What is the date of the patients last completed physical exam with lab work and appropriate diagnostics? (A complete physical is required within a 12 month period preceding the date of the trip.)*

MonthDayYear
Date

For the physician to sign:
I have examined the above applicant and DO or DO NOT consider him/her physically and emotionally qualified to participate in a rigorous foreign work project.*

DoDo notOther
Physician's name*

Physician's First NamePhysician's Last Name
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Physician's signature:

Clear

For the patient to complete and sign:

I authorize the leadership of The Friends of Israel Gospel Ministry, Inc. and their assigned representatives to release the above-described medical information to medical facilities or medical practitioners solely for use in my evaluation as an applicant or my medical treatment as a participant in either Hesed or ORIGINS under the direction of The Friends of Israel Gospel Ministry, Inc.
Applicant Name*

Applicant First NameApplicant Last Name
Applicant Signature

Clear

Important Notice Regarding Immunizations

We strongly suggest that you seek your doctor’s advice regarding his/her recommendations for further beneficial immunizations.
Should be Empty:

Rows	Yes	No
Any abnormal test or physical examination results
Any health condition, illness or injury that may require treatment
Any use of tobacco products
Any dietary requirements that may be a challenge to foreign work or travel
Any weight or mobility difficulties that may be a challenge to foreign work or travel
Any medical devices, equipment, braces, or prosthesis which are used on a regular basis
Any physical or medical limitation to lengthy air or vehicle travel
Any physical or mental condition that may impact possible roommates
Any restrictions due to physical or mental health conditions

Medical History and Questionnaire