About Us

Language and Culture Commitment Pre-Session Intensive Language Course Pre-Session Study Tour Preshco Extended Program

About Academic Course Descriptions and Syllabi Internships Location of the Facultades and Campuses Plataforma Digital

PRESHCO Culture Workshops Integration with UCO Students More Things To Do in Córdoba Cultural Reimbursements Explore Spain

Housing & Meals Boletines Useful Information while in Cordoba

How to Apply Program Dates & Fees Eligibility

Spanish Visa Travel to Spain

Images of Córdoba Student Images Videos Blogs

STAY HEALTHY IN SPAIN STAY SAFE IN SPAIN LIFESTYLE & SELF-CARE IN THE CULTURE OF SPAIN Self and Identity in Spain

Grades Grade Report Request

FALL 24 - PROGRAM ACTIVITIES FALL 24 - CLASS SCHEDULES AND ACTIVITIES SPRING 25 - PROGRAM ACTIVITIES

Contact Site Visits

LANGUAGE IMMERSION Language and Culture Commitment Pre-Session Intensive Language Course Pre-Session Study Tour Preshco Extended Program ACADEMIC IMMERSION About Academic Course Descriptions and Syllabi Internships Location of the Facultades and Campuses Plataforma Digital CULTURAL IMMERSION PRESHCO Culture Workshops Integration with UCO Students More Things To Do in Córdoba Cultural Reimbursements Explore Spain COMMUNITY IMMERSION Housing & Meals Boletines Useful Information while in Cordoba APPLICATION AND ADMISSION How to Apply Program Dates & Fees Eligibility PRE-DEPARTURE Spanish Visa Travel to Spain STUDENT EXPERIENCES AND SOCIAL MEDIA Images of Córdoba Student Images Videos Blogs HEALTH, SAFETY & WELL-BEING STAY HEALTHY IN SPAIN STAY SAFE IN SPAIN LIFESTYLE & SELF-CARE IN THE CULTURE OF SPAIN Self and Identity in Spain ACADEMIC POLICIES AND PROCEDURES Grades Grade Report Request PRESHCO CALENDARS FALL 24 - PROGRAM ACTIVITIES FALL 24 - CLASS SCHEDULES AND ACTIVITIES SPRING 25 - PROGRAM ACTIVITIES About Us CONTACT Contact Site Visits

Student Medical History Form

Name *

First Name

Last Name

Semester *

Academic Year for which you are applying *

Gender *

Home Institution *

Email *

PERSONAL HISTORY

Please check if you have or have had any of the following:

Diseases and Disorders

Chicken pox

Diabetes

Eating disorders

Epilepsy

Fainting spells

Gastrointestinal disease

Hepatitis

Malaria

Measles

Monomucleosis

Polio

Rheumatic fever

Rubella (German measles)

Scarlet fever

Tuberculosis

Other (please explain below)

Surgery

Appendectomy

Diabetes

Epilepsy

Convulsions

Hernia repair

Tonsillectomy

Orthopedic

Heart or other vital organs

Other (please explain below)

Allergies/sensitivities

Asthma

Eczema

Hay fever

Peanut

Tree nuts

Gluten

Lactose intolerance

Other (please explain below)

Personal Habits

Please list any habits that may affect your health (i.e., tobacco, alcohol, etc.)

Other

If you checked other for any of the above categories, please explain below.

FAMILY HISTORY

Please fill out your family history as it relates to the state of their health.

Age of father

If deceased or if unknown, please write Not applicable.

State of your father's health

Age of mother

State of your mother's health

Age of first sibling

If deceased or if unknown, please write Not applicable.

State of your first sibling's health

Age of second sibling

If deceased or if unknown, please write Not applicable.

State of your second sibling's health

Age of third sibling

If deceased or if unknown, please write Not applicable.

State of your third sibling's health

Additional comments about family history

REVIEW OF PAST ILLNESSES OR SYMPTOMS

Please complete the following. Do not leave any questions blank.

Has your physical activity been restricted in the past five years?

If yes, please fill out the next section.

If yes to the above, give reasons and duration.

Have you consulted or been treated by a clinic, physician, or other practitioners within the past five years, other than routine check ups?

If yes, please fill out the next section.

If yes, give reason(s) and year(s).

Have you ever been hospitalized?

If yes, please fill out the next section.

If yes, please explain the illness.

Do you have any chronic/recurrent illness?

If yes, please fill out the next section.

If yes, what is your chronic/recurrent illness?

Have you had any allergic reactions to prescription or over-the-counter medications?

If yes, please fill out the next section.

If yes, which medication(s)?

Have you received counseling or mental health treatment within the last three years?

If yes, please fill out the next two questions.

Please describe current treatment and/or medications. (This information will be kept confidential. It will only be used to provide help needed in Cordoba.)

You will need to have a mental health professional or counselor fill out an additional form.

If yes, have you discussed with your mental health counselor the idea of continuing or leaving therapy while you are abroad?

If yes, please fill out the next section.

Signature

Date

YYYY

Thank you for submitting your documents. We look forward to working with you throughout the application process.

At PRESHCO we condemn racism, discrimination, violence, and hatred toward any person or persons. This extends to host families, employees, professors, and third-party collaborators as well.

PRESHCO

176 Dothan Street,

Winchester, MA, 01890,

United States

6178356532 SBIEL@SMITH.EDU

Hours