Student

LE
2025-26
FORM M Health
Certiticato
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INSTRUCTIONTO THE STUDENT and NATURAL PARENTS:

This form must be flled out completely and accurately, Ihe English language form must BE FILLED OUT IN ENGLISH and must contain all required stamps and
signatures. If your doctor does not know English, your American Councils office will provide you with a local language form that the doctor can USe. If the docior
tillsout the local language form, roturn both that signed form, AND the translated, stamped, and signed English form along WITH YOUR APPLICATION.
Anatural parent or legalguardian must complete and sign PART A, after PART Band PART Care completed, Your phiysician must cormplete PART B, and your
dentist must complete PART C. After your health professionals complete Parts Band C, the student and parent must review the entire torm to rmake sure nothing is
missing. When you are certain that al parts of the form are complete and correct, sign and return it along with your application by the due date shown on FORM 1.

PART A,ACKNOWLEDGEMENT AND VERIFICATION: To be completed by the student's parent or legal guardan.
ACKNOWLEDGEMENT: lunderstand that:
The program does not cover costs associated with pre-existing conditions, routine check-ups, dental work (including orthodonture),
or glasses. Students and natural parents are solely responsible for these costs.
If mychild wears glasses and/or contact lenses Icertify that they will bring an adequate supply for the prograrn year.
If dental work required for my child is not completed before they depart for the United States, Iunderstand that Iam responsible for
any costs related to said dental work in the United States.
VERIEICATION: Is there any information about your child's physical, mental, or emotional health that is noton this form? Mark one: YESO No4
. If yes, please explain on a separate piece of paper and attach it to this form.
By signing this lacknowledge that 1have read and understand the points above. Ialso certify that the information in or attached to this form is accurate and
discloses ALL conditions and medications that I am aware of.
Sex: MF)
Student's
Name:
Yefimchuk
farnily name
OLha
first name
Mykolaivno
middle name
Date of
birth: A YY (circle one)

Parent's Parent's Date of

Name: Signature: Signature:
family name first nam

PART B, MEDICAL CERTIFICATION: To be completed by the student's doctor.

1. MEDICAL HISTORY: Has the student ever received treatment, attention, or advice from a physician or other practitioner for, or been told by a
physician or practitioner, that s/he had (check YES or NO):
YES NO YES NO YES NO
1.1 Asthma 1.13 Thyroid Abnormality or Disease 1.26 Mental Health Concerms
1.2 Chronic or Recurrent 1.14 Diabetes Mellitus 1.27 Learing Disability
Respiratory Disease 1.15 Other Endocrine Abnormality 1.28 Reproductive Systen Abnormality
1.3 Rheumatic Fever or
Disease
1.16 Chronic or Recurrent Arthritis
or Disease
1.4 Disease or Abnormality of the Heart 1.29 Sexually Transrmítted Diseases
1.5 High Blood Pressure 1.17 Muscle Disease or 1.30 Tuberculosis
1.6 Chronic or Recurrent Upper Skeletal Abnormality 1,31 Hepatitis A
Gastrointestinal Disorder 1.18 Chronic or Recurrent 1.32 Hepaitis B
1.7 Chronic or Recurrent Lower Skin Condition
Gastrointestinal Disorder 1.19 Cancer or Leukemia 1.33 Hepatitis C
1.20 Blood Disorder 1.34 COVID-19
1.8 Enuresis (Bed wetting)
1.9 Chronic or Recurrent Kidrney or 1.21 Eye Abnormality or Disease 1.35 Measles
Urinary Tract Discase 1.22 Hearing Impairment 1.36 Murnps
1.10 Persistent or Recurrent Headache 1.23 Anorexia/Bulimla 1.37 Rubella
1.11 Seizure Disorder (Eplepsy) 1.24 Signficant Weight Loss or Gain 1.38 Other Childhood Diseases
1.12 Other Neurological Abnormality 1.25 Psychiatric Problem or llness
or Disease

IfYES, Ís each condition: RESOLVED or ACTIVE

Date of most recernt IfYES, provide: diagnosis date of diagnosis duration of condition severity and frequency of condition Use addition al paper
Item No. symptoms or atlack treatment and medication plan how docs it affect the paticnt's daily life? if necessary.

Exainple: 14 June 2023 Active: Mitral valveprolapse, dx 2023, no strenuous sports but does not impact daily life. Needs yearly examination by cardiologist
 Student
ELEXs-26 FORM M Health
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STUDENT NAME:
Yefmchuk
famity name
QL ha
first name
Mkolaivna
middle name

student to enter school in the United States. All

2. IMMUNIZATION RECORD. An accurate and complete record will be required for the for Diphtheria, Tetanus, Pertussis,
students must meet minimum U.S. school immunization requirements
Poliomyelitis, Measles, Mumps, and Rubella. Record all dates (DAY/MONTH/YEAR) for all doses of the
following vaccines that the student has received since birth.

required by a U.S. School? Yes No Student date of birth:

2.1 Is there a medical reason the student cannot receive additional immunizations if
Ifyes, explain: 124107 03MM

DOSE3 DOSE 4 DOSE 5

DOSE 1 DOSE 2

I 2 / OR 9 0oos 03 AOG
Diphtheria, Tetanus, and Pertussisd
2.2 (DTaP. DD MM YY DD MM YY DD MM YY DD MM YY
DTP) DD MM

2.3 Tdap (Allstudents must receive EYFLEXPROGRAM

REQUIRED
a Pertussis vaccination AFTER
October 1, 2016) MM YY

2.4 Diphtheria and Tetanus

DD MM DD MM
MM DD
(Td, Dt, TD) DD

2.5 Polomyelitis(Al students must

receive at least 4 doses. At least MM YY DD MM YY DD MM YY
DD MM DD
one dose must be given after age
4. Doses given before 6 weeks of MM
DD DD MM
age are invalid) MM YY MM

2.6 Measles Mumps Rubella (MMR),

Combination vaccine only
-any dose invaid igien before age 1 MM YY DD MM MM
-f student recened indiidual doses
indicate them in sactions 215-216

2.7a Varicella (Vaccination)

REGUREDBYUS.
SCHOOLS
AND if yes, when?
Contracted disease?
2.7b Varicella (History) es No MM
Dbao5 YY

2.8 Hepatitis A
DD MM YY DD MM

2.9 Hepatitis B DD MN
MM YY
DD MM

2.10 Combination -

DD MM
Hepatitis Aand B DD MM YY MM

2.11 Meningococcal -|
(Conjugate or Serogroup B) MM YY MM

2.12 Tuberculosis (BCG)

DD MMYY DD MM

2.13 COVID-19 vaccination

NAME MM YY DD MM
DD YY DD

2.14 COVID-19 vaccination

NAME YY DD MM YY D MM VY
DD

2.15 Other dosesVaccinations

NAME
COMPONENT ( combination vaccine): MM YY DD MM MM
MM

2.16 Other dosas/Vaccina ions

NAME MM MM DD MM
DD
COMPONENT (f Combination vaccine):
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STUDENT NAME: fimchuk

family name
(lha tirst name
Mykolaivna
middle name

In order to onter school in theUnited States, it is requirod that the student be scroened
3. SCREENING FOR PULMONARY TUBERCULOSIS: for tuberculosis.
3.1 TESTING: TB testing can be ElTHER a Skin Test ORaBlood Test performed after September 1, 2024.

OPTION 1: T8Skin Test OPTION 2: TB Blood Test **ATTACH LAB REPORT'*

Results of QuantiFERONE-TB Gold or T-SPOTO TB test
Results (Mantoux PPD) mUst be read 48-72 hours after placement"

Date Placed: ONegative OIndeterminate

MM Y Check one: O Borderline
OR O Positive

Date Read:
MM Date of Test:
ATTACH LAB REPORT DD MM
#mm lnduration: milimeters
If the skin test result is fomn or greater, provide the results of a current
If the blood test result is positive, indeterminate or borderline, provide the
results of a current chest X-ray in #3.2 below.
chest Xray in #3.2 balow.
3.2 CHEST X-RAY
Achest X-ray is necessary ift A) the skin test result is 10mm or greater; -OR B) the blood test result was positive. indeterminate or borderline.
The date of the nomalchest X-ray must be on or after the date of the skin or blood test. Provide the results below:

Date of X-ray: Chest X-ray result (check one): Normal (-) Abnormal (+)
MM

4. SYMPTOM REVIEW (mandatory): Does the student currently have any of the following symptoms (check yes or no for each symptom)?

4.1 Prs stentcough |yes 4.2 Fever or Yes4.3 ympth gland OYes 4.4 Bloody Yes4.5 Recent or Yes4.6 Sharp chest Yes
sputum: unexplained pain when
for more than night sweats: enlargement: weight loss: UNo coughing: ho
two weeks No No
4.7 Ifyes to any synptoms, a chest X-ray taken on or after the date of the TB skin or blood test must be provided below:
Date of X-ray: Chest X-ray result (check one): DNormal (-) DAbnormal (+)

5. PHYSICAL EXAMINATION: Complete the following section based on your physical examination of the student.
Date of Examination: Height(meters): Weight (kilograms): S3
Blood Pressure (in mmHg): systolic: O diastolic: Pulse (beats per minute):
DD NN YY

PHYSICAL EXAM. Please indicate any current abnormalities of the following:

NORMAL ABNORMAL NORMAL ABNORMAL

5.1 Eyas (0Mark ABNORMAL If vision loss is not correctable): 5,8 Urinary System:
5.2 Ears: 5.9 Thyroid Gland or Endocrine System:
5.3 Nose or Throat 5.10 Reproductive System:
5.4 Lungs or Respiratory System: 5.11 Musculoskeletal System:
5.5 Heart or Cardiovascular System: 5.12 8rain or Nervous System:
5.6 Abdomen or Abdominal Organs: 5.13 Skin:

5.7 Icertify that the student can

participate in school sports: Yes No O If no, explain.

If ABNORMAL, " diagnosis "date of diagnosis recommended monitoring or treatment (includng medications or surgery) Use additional paper
Item No. provide: -need tor follow-up care how does it atfect the patient's daily lite? if necessary.
 Studernt
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STUDENT NAME: Yefimnchu
tamily name first name middle name

6. QUESTIONS FOR THE PHYSICIAN: Check Yes or No box for cach question. If "Yes, provide requested details in the second
column,Use additional paper if necessary.
QUESTION: IF ANSWER IS YES:
6.1 Has the student ever had surgery not Name(s) of surgery: Date(s) of surgery (dd/mmlyy)
revealed in previous questions? OYes NO Result of surgery:
6.2 Has the student ever received inpatient Dales of inpatient care (dd/mmlyy): Reason for inpatient care:
care in a hospilal, clinic, or sanatorium? OYes No
6.3 Has the student recently been advised to Name(s) of surgery needed: Date(s) of surgery needed (dd/mnlyy)
have surgery or addilional medical car? OYes No Type of additional care needed:
6.4 Has the student taken any prescribed For what condition: Name of medication(s) and dosage
medication in the past 12 months? OYes No Wil the studentcontinue to lake this pre scribed medication in the U.S.? OYes ONo
6.5 Wil the student require routine nmedical Monitoring for what condition(s): Type of monitoring:
monitoring or care while in the U.S.? OYes KNo Frequency of monitoring:
6.6 Does the student have any limitations Why? List the limitations:
in physical activity? OYes tNo
6.7 Does the student have any allergies? Ofood: Type of allergic D anaphylaxis Dlocal reaction (describe)
If yes give name of all allergens. OYes No Omedicine: reactíon: Dother (describe):
O insect. Response D none D epinephrine auto-injecior
D other: required: D medication: O other
Cause:
6.8 Has the student ever had anaphylaxis? OYes MNo Date(s) (dd/mm/yy):
Treatment:
6.9 Has the student ever had a head injury Date(s) (dd/mm/yy): Cause:
or traumatic brain injury (concussion)?
OYes Na Treatment:

6.10 Has the student ever (including now) Name of diagnosis: Dale of diagnosis (ddlmmiyy):
had aa speech problem (ior example, OYes tNo Need for ongoing treatment: Current status:
speech impediment, lisp, or other)?
6.11 Does the student have any dietary restrictions fo Reason/Condition
health reasons (examples: gastritis, nut allergy)? Yes VNo Excluded foods:

6.12 Is the student significantly overweight Reason/Condition:

or underweight? O Yes No Treatment:

6.13 Has the studeril ever consulled a

psychologist or psychiatrist? OYes No Dale of consultation(s): FROM: (ddlmn'yy) TO (dd/mmlyy
Diagnosis:
6.14 Has the student ever abused alcohol, or Date(s) (ddimmiyy): When last used?
drugs such as opiates or barbiturates? OYes VNO What:

6.15 Does the student wear glasses or Check one: OGlasses O Contact lenses O Both
conlact lenses? OYes No
6.16 1s there any medical reason why the Reason:
Yes MNo
student should not participate in this program?
6,17 Has the student ever been tested for HIV? Date(s) (dd/mm/yy):
OYes No Result:

6.18 Has the student recently had COVID or VIRAL TEST DATE (dd/nniyy): ANTIBODY TEST DATE (dd/mmiyy)
complications from COVID infection? OYes No Result: D Positive O Negative Result: DlgMpositve QlgG positive QBoh igM &IgG positive DNagative
What is the general state of stude't's health? (check one): How long has this person
been your patient?
3Years
Months
If known less than a year, do you know OYes
the student's complete medical history? D No
OExcellent GoodPoor

PHYSICIAN YIGNATURE
Q3 / , 202
DATE (dd/mmiyy)
BPA ATO

PART C. Dental Certification To be completed by the student's dentist within thepastyea

1,0 Are the student's teeth and gums in healthy condition? Yes ONo DATE OF EXAMINATION:t.04.J04 DD/MM/Y BinnoetasábMic
1.1 If no, explain in detail:
1.2 If dental work is needed, provide the date it was completed, or will be cormpleted. DATE: .09. 2024 DD/MM/YY
2.0 The student wears: A) fixed braces? OYes No B) removable orthodontia devices? O Yes
Ifthe student wears fixed braces, will they be removed before the student departs for the U.S.? O Yes No ON/A
2.1
2.2 Is any follow-up required on fixed braces or orthodontia devices while in the U.S.? Yes VNo l yes, exolain:
2.3 Will removable orthodontia deviçs berescribed when the fixed braces are removed? OYes No

DENTIST SIGNATURÉ DATE (DD/MIA/YY)