Past and Present Illneses

Volunteer Medical Report

Applicant’sFirst name:

Last name:

Date of Birth:

Blood pressure reading:

PAST AND PRESENT ILLNESES

Heart problems? ☐Yes☐ No

Lung problems? ☐Yes☐ No

Asthma? ☐Yes☐ No

Emphysema? ☐Yes☐ No

Hypertension or other related disorders? ☐Yes☐ No

If yes, please explain:

Allergies? ☐Yes☐ No

If yes, is the applicant taking drugs to control the allergies?

☐Yes☐ No

Which ones?

Neurological problems?

☐Yes☐ No

Arthritis? ☐Yes☐ No

Diabetes mellitus? ☐Yes☐ No

Chronic skin diseases?

☐Yes☐ No

Respiratory diseases: tuberculosis, chronic bronchitis, bronchiectasis, sinus disease or others?

☐Yes☐ No

Urinary tract disease?

☐Yes☐ No

Epilepsy, fainting spells, history of head injuries? ☐Yes☐ No

Diseases in the digestive track?

☐Yes☐ No

Does the applicant have back trouble? ☐Yes☐ No

Any major injuries, surgery or cancer treatment? ☐Yes☐ No

If yes, please give dates, complications and residual symptoms:

Please list other conditions and diseases:

Can the applicant do manual labor? ☐Yes☐ No

List all medications and dosages currently being taken:

PHYCHOLOGICAL PROFILE

In your opinion, is the applicant a flexible and agreeable person?

☐Yes☐ No

Has the applicant a history of depressionor other mental problems? ☐Yes☐ No

Treatment by a psychiatrist (past or present)? ☐Yes☐ No

Has there been any use of medication for psychiatric disorders?

☐Yes☐ No

If so when?

And for how long?

Is the applicant capable of working with others? ☐Yes☐ No

Please comment if necessary:

Yafo Street 208 * P.O. Box 36163 * Jerusalem 91361 * Israel * Tel. +972 2 5011103 * E-mail:

Volunteer Medical Report

Bearing in mind the various conditions imposed by volunteering in Israel (lengthy absence from home, adjustment to a foreign culture, simple living conditions,little privacy, stressful political situation, new social contacts etc.) will you please give us your evaluation of the applicants emotional stability.☐ Unstable /☐ ReasonablyStable /☐Stable

Please complete: I have examined the above named applicant and ☐I DO / ☐DO NOT consider him / her physically and emotionally qualified to volunteer with ALEH in Israel.

Physician's name, address and city: / Telephone:
Physician's signature and stamp:

Yafo Street 208 * P.O. Box 36163 * Jerusalem 91361 * Israel * Tel. +972 2 5011103 * E-mail: