Health and Wellness Form

Name*
First Last
Email*
Phone*
City you are serving in:*
- Boston, MA
- Minneapolis/St. Paul, MN
- Philadelphia, PA
- Portland, OR
Emergency Contact Name*
First Last
Emergency Contact Relationship*
Emergency Contact Phone*
Emergency Contact Email*

Please briefly describe your general state of health--mentally, physically, emotionally (as you perceive it).*
Do you have any medical conditions which might affect your service or assignment?*
- Yes
- No
Please describe medical conditions which might affect your service or assignment.*
Detail physical challenges, or illnesses such as asthma, colitis, endometriosis, migraines, arthritis, or any other chronic health conditions.
Are you currently taking any medications (over the counter or prescription)?*
- Yes
- No
Please list the medications you are taking and why.*
Allergies: Please list any symptoms that you experience from exposure to allergens (i.e. rash, breathing problems, etc.) and any medication you use to treat these allergies.*
Do you anticipate requiring prescription medication during your service year?*
- Yes
- No
Please list prescription medications you will require during your service year.

Alcohol and Drug Use
The following questions are about drug and alcohol use. QVS expects Fellows to have transparent conversations about community needs related to substance use.
Do you consume alcohol?*
- Yes
- No
How many drinks/day or drinks/week?*
Do you use non-prescribed or recreational drugs?*
- Yes
- No
How many times per week do you use drugs?*
Have you ever been diagnosed or treated for alcohol or drug addiction?*
- Yes
- No
What should we know about helping you stay healthy while you share living space with housemates who may use?*
If you have discomfort around drug and alcohol use, what should we know about helping you stay healthy while you share living space with housemates who may use?

Have you ever received a mental health diagnosis from a mental health professional? Examples of conditions include anxiety, depression, OCD, ADHD, bipolar disorder, and schizophrenia. Please also check yes if you struggle with disordered eating.*
- Yes
- No
Please describe your diagnosis, and any ongoing treatment or issues.*
Have you utilized support from therapists, counselors, psychologists, or other mental health professionals? Note: QVS may be able to help arrange ongoing therapy during your service year, but cannot help you if we are not aware of your needs.*
- Yes
- No
If you have any current medical or mental health concerns, what plans do you have for self-care and treatment while in QVS? What resources or accommodations might you need?*
Sometimes our staff has asked QVS Fellows to seek counseling if they think talk therapy might support their needs. How would you respond if QVS staff recommended that you seek counseling?*

Alcohol and Drug Use