Go Global Application & Programme Overview
How we use your details:
Details given on this form may be shared with medical staff, University staff accompanying
the trip, and University staff based in the UK, as well as partner universities in the country
you are visiting, where no University of Bedfordshire staff member is accompanying the
trip, should you become ill and need medical treatment and are unable to advise relevant
medical staff yourself.
Please complete the following medical questionnaire to the best of your ability, by marking
an X in the relevant box. Please note that for certain conditions i.e., mental health
conditions and pregnancy, we would require written approval from your GP allowing you to
Do you have or have you had in the past: Ye s No
If YES, please give details of any
treatment/medication you are taking
Angina, raised blood pressure or other heart
Eyesight problems not corrected by glasses/
contact lenses? E.g restricted vision, glaucoma, etc.
Hearing problems not corrected with a hearing aid
such as restricted hearing, tinnitus, or ear
Are you taking or are you being given any
medicines, inhalers, injections or eye/eardrops at
the present time?
Any difﬁculty in standing, bending, lifting or other
Any kind of back problem?
Any kind of neck or shoulder
Any problems with your joints including pain,
swelling and stiffness? For example, arthritis,
rheumatism, upper limb disorder, tennis elbow etc.
(WOMEN ONLY) Are you pregnant or have you had
a child in the last 6 months?
Bronchitis, pleurisy, tuberculosis, coughing up
blood, shortness of breath or other chest problems
(within the last ﬁve to ten years)?
Any ﬁts, blackout, fainting or epilepsy?
Depression, stress, anxiety or other mental health
problems such as panic attacks, sleep deprivation
which have caused you to seek medical advice?