PERSONAL HISTORY. In order to understand our clients’ background, and to assist in establishing the most suitable structure and banking arrangements (if required), information regarding our clients’ work experience and qualifications is likely to be of considerable assistance, together with a clear understanding of our clients’ wealth financial circumstances both past and present.
PERSONAL HISTORY. The Employee represents and warrants to the Employer that there is no scandal, whether or not involving a criminal conviction, in his/her past which if made public during his/her employment with the Employer would tend to harm the reputation of the Employer, whether among the public at large or among the clergy, employees or volunteer staff of the Employee.
PERSONAL HISTORY. 1. Have you, individually, as a partner, joint venturer or as an officer of a corporation had a bond or surety canceled or forfeited within the last ten (10) years? Yes. Provide information below. No Bond Company Name Bond Date Bond Amount Explain the reason for each cancellation or forfeiture.
PERSONAL HISTORY. A. Does Participant have allergies to any medicines, foods, bites and stings, etc? O yes O no If “yes”, please list:
PERSONAL HISTORY. 3. Do YOU have a history of the following? □ YES □ NO A. Fainting/dizziness during or after exercise? □ YES □ NO B. Respiratory Problems (pneumonia, bronchitis, sinus problems)? □ YES □ NO C. Chest discomfort during exercise? □ YES □ NO X. Xxxxxx or Wheezing? If yes, which medication/inhaler? □ YES □ NO E. Seizures, Convulsions, Epilepsy? □ YES □ NO F. ADD or ADHD? □ YES □ NO G. Heart disease (rheumatic fever, murmur)? □ YES □ NO H Anorexia/Bulimia/Eating Disorder? □ YES □ NO I. Chronic Skin Disease (e.g. eczema, psoriasis)? □ YES □ NO J. Hepatitis/Yellow Jaundice/Kidney/Bladder Disease? □ YES □ NO K. Abdominal Issues, Digestive Tract Disease (ulcer, colitis, etc.) or Hernia? □ YES □ NO L. Frequent or Severe Headache (migraine)? □ YES □ NO M. High Blood Pressure/Cholesterol? □ YES □ NO N. Depression or Anxiety? □ YES □ NO O. Speech, Hearing, or Vision Problems? _ □ YES □ NO P. Sexually Transmitted Disease or HIV? □ YES □ NO Q. Cancer (skin, thyroid, etc.)? □ YES □ NO R. Thrombophlebitis or Blood Clots? □ YES □ NO S. Thyroid, Endocrine Disturbance, or Diabetes? □ YES □ NO T. Other medical illnesses? HEAD INJURIES
PERSONAL HISTORY. Xxxx (re-named for purpose of case study) was a 71-year-old lady of Pakistani origin who had lived the majority of her early life in Kenya. She married at the age of 24 and had three children. Her husband immigrated to the UK shortly after the birth of their first child to study and she joined him in the UK a few years later. In the UK Xxxx lived with her husband’s extended family and throughout her life fulfilled the role of caregiver for the family network. Xxxx also worked in the family business alongside bringing up her children. Xxxxx’s husband died 7 years prior to the current referral and her son, daughter- in-law and grandson moved in with her after his death. Xxxx was of strong Muslim faith and had played many care giving roles within her community.
PERSONAL HISTORY. Do you ever have any injuries, difficulties or problems during a high intensity exercise? If so, please Specify _ _.
PERSONAL HISTORY. Have you had any major injuries or accidents? ❑ No ❑ Yes If yes, please list with dates: Have you had any major illness, surgery or hospitalizations? ❑ No ❑ Yes If yes, please list with dates: Are you pregnant or could you be pregnant? ❑ No ❑ Yes If yes, how many months? Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past. Digestive System: Abdominal pain Belching Constipation Diarrhea Food Cravings Gall stone Gas or Bloating GERD’s or Heartburn Hemorrhoids Hepatitis IBS Nausea Poor Appetite Ulcers Other: Number of bowel movements daily? Are they? ❑ Loose ❑ Normal ❑ Hard ❑ Incomplete Nervous & Endocrine System: Anxiety Brain fog / Cloudy thinking Depression Difficulty concentrating Fatigue Headaches Hot flashes Hormonal imbalance High Stress Irritability Mental illness Mood swings Numbness or tingling Poor sleep Poor memory Racing thoughts Thyroid dysfunction Other: Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past. Immune: Allergies Auto-Immune condition Cancer Chemical sensitivities Chronic infection Hives Herpes Fevers Frequent colds or infection Swollen glands Other: Musculoskeletal:
PERSONAL HISTORY. In answering each of the questions, select the appropriate box next to each question. For each “YES” answer, a separate, signed statement giving full details, including date(s), location(s), action(s), organization(s) or parties involved and specific reason(s) must be included with the application/proctection agreement . Read the definitions listed below before completing the personal history questions. “Ability to practice within your profession with reasonable skill and safety” means ALL of the following: o cognitive capacity, o ability to communicate with patients and other health care providers, o capability to perform health care services within your profession. “Medical condition” means any physiological, mental, or psychological condition, impairment, or disorder, including drug addiction and alcoholism.
PERSONAL HISTORY. As a member of the community at Summit Pacific College and potentially a credential holder of the Pentecostal Assemblies of Canada (PAOC), students need to be willing to comply with lifestyle commitments belonging to the community, which involve abstention from alcohol, tobacco, non-medical drugs, occultic activity and separation from all suggestion of immoral or unethical behavior. As Summit Pacific College is the educational arm of the PAOC we affirm lifestyle values that are consistent with credentialing responsibilities. Have you been involved with any of the above mentioned in either the past or present?
