MDA Medical Form

NOTES TO THE EXAMINING PHYSICIAN
The new and strenuous environment each participant will face will tax his/her physical and mental
capabilities to the fullest. It is therefore imperative, as a safeguard to the health of the participant
that this report be as complete and precise as possible. This form should be filled out by a physician
who has known the applicant for at least 18 months prior to the filling out of this form. In addition,
any applicant who has been under the care of a specialist (for example, cardiologist, neurologist,
psychiatrist, psychologist, social worker etc.) must submit a detailed report from that specialist giving
a complete diagnosis, prognosis and evaluation.
If a participant is required to continue receiving medication while under the auspices of the program,
he/she should have a medical letter giving full details. Since in many cases medicine is not available
under the same trade name as in the country of origin, the full pharmacological name of all medicines
and drugs used by the patient should be given. In any event, the participant should bring an extra
supply of the medicine with him/her as it will not be covered by their medical insurance.
If any changes take place in the participant’s condition following the examination and prior to the
beginning of the program, the participant must submit, before departure, an explanatory medical
letter, detailing diagnosis, prognosis and treatment. Failure to submit such a letter shall result in the
expulsion of the applicant from the program with no refund.
FOR YOUR INFORMATION
1. Climate: Participants will be volunteering and living in a sub-tropical climate, with

temperatures reaching 100 degrees Fahrenheit/ 37 degrees Celsius. The climate is mostly dry with
semi-arid conditions over a large part of the country.
2. Social Environment: Most participants will be living in a communal environment. They will be
sleeping in a dormitory or sharing living quarters with others.
3. Medical Facilities: The physician should bear in mind that medical facilities are available for
acute illnesses and accidents only and do not cover routine, chronic or any kind of pre-existing
conditions.
VACCINATIONS
Please note that immunization against Hepatitis B and MMR is compulsory for all participants.
The participant must have had 2 vaccinations against MMR and between 2-3 vaccinations against
Hepatitis B (depending which country they come from) before the start of the program. We
recommend that the participant receive a Tetanus vaccine as well.
PLEASE NOTE:
The Israel Experience Ltd. intends to rely on this completed form and supplementary letters in making
the determination of acceptance of the participant to the program. Omissions or mis-statements
are at the risk of the applicant and his/her physician, psychiatrist, psychologist / social worker.
The information on this form and all supplementary reports on the physical and mental state of the
applicant will be held by the Israel Experience Ltd. as strictly confidential.
Should any participant, upon arrival in Israel, or during his/her stay, be found to be suffering from
any condition, mental or physical, that is not fully disclosed in this medical form or accompanying
letter then:
He/she may, at the sole discretion of the program coordinator, be returned to his or her home country
at his/her own expense (with no refund from the program)
The Israel Experience Ltd. And\or Magen David Adom and its representatives in Israel are thereby
released from responsibility or liability of any kind whatsoever arising from any aspect of such
participants medical history and/or physical and mental condition.
Participant name:
PHYSICAL EXAMINATION
(To be completed by a licensed physician)
DESCRIBE
NORMAL ABNORMAL ABNORMALIT
Y
Head
General Build
Neck
Ears
Eyes
Teeth
Mouth, Throat
Chest, Lungs
Heart
Vascular System-
Abdomen & Viscera
Hernia
G.I. System
G.U. System
Upper Extremities
Lower Extremities
Spine
Skin, Lymphatic
Nervous System
Weight: _____________ Height:_________________ Blood Pressure: ________________

Pulse:_______________Respiration: _____________Hearing:_________________
Vision: ______________Any abnormal findings: ________________
Allergies: ________________________________________________________________
_________________________________________________________________________
Chronic illnesses:__________________________________________________________
________________________________________________________________________
Surgeries:________________________________________________________________
_________________________________________________________________________
Any medical issues: _________________________________________________________
_________________________________________________________________________
Can s/he work under pressure: yes/no
Does s/he have any limitations to carrying heavy things: yes/no
HEP B immunization:
3 Dates of receiving Hep B Immunizations: (1)_________________ (2)__________________(3)

_____________
MMR immunization:
2 Dates of receiving MMR immunizations: (1) ______________ (2)____________________
Doctor's stamp\signature on Hep B/ MMR Vaccinations:
______________________________________Date:____________________________
__
PHYSICIAN’S STATEMENT
I have completed an examination of ___________________________________ whom I have known

for _____ years. The results I have recorded represent, to the best of my knowledge, the entire
participant’s medical history and my findings on examination. I understand that the program organizers will rely
on my report and findings. In my opinion the participant is physically, mentally and emotionally capable of
participating in the program.
I recommend full physical activity and the participant is suitable for full EMT ambulance field work: YES/
NO
If NO, please explain why:
_________________________________________________________________________________
I recommend certain restrictions: YES/NO. If YES, please explain why:
_________________________________________________________________________________
I recommend a special diet: YES/NO. If YES, please explain why:
_____________________________________________________________________________
Name of Physician (please print):
Address:
Email:
Telephone:
Date: Signature of Physician:
License Number:
PARTICIPANT’S STATEMENT
I hereby certify that, to the best of my knowledge, this medical form is complete in all its details and I fully realize
that any condition, mental or physical, that I am found to have, originating prior to the beginning of the program,
and which is not described in full in this form or in an accompanying letter, will be due cause for my return to
my country of origin, or treatment in Israel, solely at my expense, and that the program organizers have neither
responsibility or liability arising out of such a condition.
All medication that I take regularly is at my own expense, and has been detailed on this form or accompanying
letter. I also give my full permission for all treatment of any nature deemed necessary by doctors in Israel to be
extended to me within the framework of the Medical Services of the program’s organizers in Israel.
Name of participant:
Date:

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NOTES TO THE EXAMINING PHYSICIAN

FOR YOUR INFORMATION

1. Climate: Participants will be volunteering and living in a sub-tropical climate, with

Abdomen & Viscera

Weight: _____ Height:_ Blood Pressure: ________

3 Dates of receiving Hep B Immunizations: (1)_ (2)__(3)

2 Dates of receiving MMR immunizations: (1) (2)______

Doctor's stamp\signature on Hep B/ MMR Vaccinations:

I have completed an examination of ___________________________________ whom I have known

If NO, please explain why:

I recommend certain restrictions: YES/NO. If YES, please explain why:

I recommend a special diet: YES/NO. If YES, please explain why:

Name of Physician (please print):

Date: Signature of Physician:

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