SHO requires that the following confidential form be filled out to the best of your knowledge and ability. The following questionnaire will be used by the staff of SHO and its participating medical professionals as a direct resource to access a detailed record of your past medical history for internal purposes, in the unfortunate case of any health-medical related incident or accident, big or small. SHO needs to know your medical history in detail and up front, and asks you in what follows to provide this information in detail through the use of this Health Background form, which we consider an official and binding document. This is a document we consider to be of critical importance, thus we ask, and thank you in advance. for your conscientious and thorough participation in its completion.
We deem it necessary to have such a record of this information in order to be able to effectively and quickly collaborate with the medical professionals (or other parties concemed in the immediate situation in which you find yourself hurt, uncomfortable. compromised, etc. and, in short, to have one more copy on hand of valuable information concerning your overall physical and mental well-being, as the main goal of SHO is to create an atmosphere that keeps students' health and happiness in the forefront of its ethic as well as its programming as its ultimate and inflexible standard. Please also note: If you are unsure of how to properly and completely fill out the following prompts about your medical history. please consult your parents or guardians who can assist you, or secure access to your official medical records from the appropriate professional sources in which you have previously dealt with.
Finally: It is important that SHO personnel be made aware of any medical as well as emotional problems/issues, past or current, which might affect you in a foreign study context. Mild physical or psychological conditions can become more serious when subjected to the unavoidable stress of traveling and studying abroad or "newness'. more generally. SHO will make every reasonable effort to accommodate the needs of students, but it may not be able to accommodate all individual needs or circumstances due to conditions beyond its control.
This short questionnaire is to be filled out by you (prospective SHO student)or yourhealth practitioner/family doctor:
1. You know of an occurrence of the following diseases and symptoms in you/your patient as well as your/their direct relatives: Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Long QT Syndrome
2. You know that within your/your patient‘s family history a sudden death occurred due to cardiovascular causes within an hour at the age of at least 50 years old
3. You know that you/ your patient or one of your/their immediate relatives have/has serious arrhythmia
4. You know that the disorder of blood coagulation or thrombophilia has occurred in you/your patient or one of your/their immediaterelatives.
5. You have/your patient has been diagnosed as having a congenital heart defect, and if so, what sort
6. I/they have been treated for myocarditis
7. I/they have had heart treatment, and if so when and what kind of diagnosis
8. I/they have been treated or investigated for hypertension
9. I/they have been investigated for arrhythmia
10. I/they have been investigated due to a state of collapse, syncope
11. There has been in you/your patient a detected heart rhythm disorder; if so, what in which terms; please attach an ECG if available
12. I/they have received an ECHO Cardiogram-Stress test; if so, for what reason, with what results, and where the test was conducted; please attach reports if they are available
13. I/they have been treated for chronic sinusitis or tonsillitis
14. I/they have been treated with antibiotics more than 3 times per year for 2 or more consecutive years; and if so for whichdiagnoses?
15. I/they have been investigated for an immune disorder; if so, which
16. I/they have been investigated for autoimmune diseases; if so, which
17. I/they have been investigated for neurological diseases; if so, which
18. I/they have been treated for a mental disease or disorder; if so, which
19. I/they have been treated for asthma or another lung disease; if so, what kind of diagnoses have there been
20. I/they have been treated for anemia; if so, which type
21. I/they have an inborn or acquired musculoskeletal defect; if so, what kind