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    Au Pair - Additional Medical Information Form

    Uploaded by

    anajuliaroque2004

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Au Pair - Additional Medical Information Form

    Uploaded by

    anajuliaroque2004
    7 views2 pages

    Copyright

    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    7 views2 pages

    Au Pair - Additional Medical Information Form

    Uploaded by

    anajuliaroque2004

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    NAME: Ana Julia da Rocha Roque MEMBERSHIP: Experimento

    ADDITIONAL MEDICAL INFORMATION FORM

    1. Name of medical condition, including a brief description of the main symptoms:

    Hypothyroidism (Underactive Thyroid)

    Main symptoms: Weight gain and difficulty losing weight, feeling cold, dry skin and hair

    2. Do you know what caused this condition?

    I have a hereditary disease that is also common in my family.

    3. What treatment/therapy was/is needed?

    Yes, medicine

    4. Please describe any effects your medical condition has on your daily life (please include any
    limitations/restrictions):

    I do not have any medical conditions that affect my daily life. I don't experience any limitations or restrictions in
    my daily activities.

    5. Are you currently taking medication for this condition? YES X NO☐

    – Name of medication: Puran T4 100mg (levotiroxina sódica)

    – How often do you take this medication? Every day

    – Do you experience any side effects with this medication? YES ☐ NOX

    If YES, please, give details: -

    – How long do you expect your medication to continue?

    For the rest of life

    6. When did your doctor first diagnose this condition? 20/06/2017

    – At the time of the diagnosis were you prescribed medication? YES X NO☐
    If ‘Yes’ please detail (including dates, name of medication and when medication was used): Puran T4
    100mg (levotiroxina sódica), since 2017.

    – If you are no longer taking this medication, when was it last prescribed to you? -

    – Have you suffered from this condition in the last 12 months? YES☐ NOX

    If yes, how frequently has the condition occurred?

    ☐ Weekly ☐Monthly ☐6 monthly ☐ Other

    Please, give details:

    7. Are there any factors that are likely to cause a reoccurrence? YES☐ NOX

    If YES, please, give details:

    8. Are there any follow up appointments/treatment required? Yes, once a year, just checkup.

    9. When did this condition end? There is no end

    10. When was the last time you saw your doctor regarding this condition? 09/01/2024

    11. Have you ever been admitted to hospital in relation to this condition? YES☐ NO X

    If YES, please, detail when and how long you were in hospital:

    12. Please provide any additional information that you think is relevant.

    PLEASE NOTE: AU PAIR IN AMERICA INSURANCE DOES NOT COVER PRE-EXISTING CONDITIONS OR ANY ASSOCIATED
    MEDICATION.

    I hereby confirm that I have completed this form fully and honestly, and that all the information above is correct. I
    understand that non-disclosure of my full medical condition could result in cancellation from the program.

    SIGNATURE ___________________________ DATE 23/01/2024

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