Health Information Form

Health Information

This information is to help SAI be of maximum assistance to you should the need arise during your study abroad experience. Please indicate any medical or emotional issues, past or current, that might affect you in a foreign study context. The information provided will remain strictly confidential and will be shared with the appropriate professional only if pertinent to your own well-being.

Name (as it appears on your passport)*

First Last

Email*

Enter Email Confirm Email

SAI Program you are attending*

Session*

(e.g., Fall Semester, Summer II, Jan Term, etc.)

Year*

Do you have any medical conditions (including allergies) or physical disabilities?*

Please note: SAI health insurance provides limited coverage for congenital anomalies and pre-existing conditions. Please contact your Admissions Counselor to understand your options.

Yes
No

Please Explain:*

Have you been treated for any psychological or emotional issues in the last five years?*

Yes
No

Please Explain:*

Have you experienced any major injuries, diseases or other ailments in the last five years?*

Yes
No

Please Explain:*

Are you currently taking any medications?*

Yes
No

If Yes, please list medication and reason for taking it*

Please ensure that you have read and understand the instructions for traveling with prescription medications. If you have questions, contact your Admissions Counselor.

Do you have any dietary allergies or restrictions?*

Yes
No

Please Explain:*

Have you received a flu shot for this season?*

Yes
No

COVID-19 Information

The following questions are specifically related to COVID-19, and are intended to help us provide you with the best support and services.

Have you ever tested positive for COVID-19 (antigen or antibody)?*

Yes
No

If Yes, when?*

Do you have any of the underlying conditions identified by the CDC as leading to higher risk for severe illness from COVID-19?*

This includes cancer, chronic kidney disease, COPD, obesity, serious heart conditions, sickle cell disease, type II diabetes, and weakened immune system due to solid organ transplant.

Yes
No

If Yes, please explain*

Will you have received a COVID-19 vaccination before you arrive in your host city?*

Yes
No

If YES, when was your most recent dose administered?

Additional Information

Is there any medical information not already on this form that you feel SAI should know?*

Yes
No

Please Explain:*

I certify that the information on this form is true and correct and I will notify SAI of any relevant changes in my health that occurs prior to the start of the program. I further understand that in the case of an emergency abroad SAI reserves the right to notify my parent(s) or guardian and my home university.

Signature*

I understand that typing my name below constitutes a legal signature confirming that I acknowledge and agree to the above statements.

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