DTS Application Medical Report

    To the physician

    The applicant has applied for a course with the University of the Nations.

    This is a short-term Christian service course in which there will be some physical exertion over a period of a possible 20 weeks of training and study in a group situation with travel throughout Cambodia.

    Thank you for completing this Medical Report for us.

    Name of applicant

    Name of physician


    Questions regarding the applicant's health

    Weight (kg)

    Height (cm)

    Is the applicant under medical supervision at this time or taking medication? (If so, what kind?)

    Would you consider the applicant in good physical health?

    Is the applicant's chest, heart and blood pressure normal?

    Is the applicant's sight, hearing and speech normal?

    Does the applicant have good emotional and mental stability to undertake such service and training?

    Please list any significant problems

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