Church of God World Missions Medical Frontiers Health Questionnaire GENERAL HEALTH (Please choose one) DISCLAIMER: Your answers do not exclude from consideration for this mission trip Excellent Good Fair Poor Are you able to walk long distances? Yes No Are you able to stand for long periods of time? Yes No Allergies:Pertinent Health History:Medication List:I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.PrintSignatureDate MM slash DD slash YYYY
