Medical Information Form – Budapest Semesters in Mathematics

BSM Medical Information Form

This medical information sheet is for precautionary measures and is required by ¶4.2 of the BSM contract. In the event of a medical emergency, this form will be a source of reliable information, so it is important to complete it listing all medical conditions. The medical information will be accessible only to our staff in Budapest and the North American Office. All fields are required to participate in the program.
I affirm the information provided in this form is complete and accurate.*
I affirm the information provided in this form is complete and accurate. I assume full responsibility for any undisclosed physical or psychological conditions that might impair my ability to complete the program. Check the box below to confirm.
- I agree
Name*
First Last
Primary Insurance Carrier*
BSM students are required to have an appropriate Health Insurance Policy for your stay in Hungary and for the Residency Permit. You will need to contact your health insurance company and request a letter and bring it with you to Budapest. This letter needs to be more than “proof of insurance” and needs to include language detailing coverage (Up to $50,000.00) while you are out of country. If your insurer does not have a template for such a letter you should request the following details to be included in a letter: your name, policy number, dates of coverage, general medical coverage while traveling, hospitalization coverage while traveling.
Primary Insurance Code/Policy Number*
Authorized Emergency Contact Person*
Enter the name, phone number and email address.
Medical Power of Attorney (if applicable)*
If not enter "NONE" or enter the name, phone number and email address.
Do you wear glasses?*
- Yes
- No
Do you wear contacts?*
- Yes
- No
Eye Prescription
If you wear glasses or contacts, please list your prescription information.
Allergies*
Please list all known allergies. Use the Ctrl key on a PC or Command key on a Mac for multiple selections.
Allergy Specific Information
If you answered yes to any of the allergies, please be more specific so we can best prepare.
Medical Conditions*
Do you have any of the following pre-conditions? Use the Ctrl key on a PC or Command key on a Mac for multiple selections.
Medical Conditions Specific Information
If you listed or selected any of the above medical pre-conditions, please provide specific details so we can plan accordingly.
Mental Health*
Please note that BSM has a psychologist on-site with limited hours. Counseling is available in Budapest but is very different than in the U.S. and with limited access. Please contact our staff in Budapest for more information. List any mental health conditions in the text box below. If you answered "yes" or listed any conditions, please consult your physician or psychologist (health care provider) before you plan to travel abroad.
Prescription Medication*
Will you be taking any prescription medication while in Budapest? If so, please list all medications, the dosage, and the reason you are taking it. You will need to bring enough medication for your entire stay and a doctor's note certifying that you need the medication. Important: it is illegal to mail prescription meds from the U.S. to Hungary. *If you are taking daily medications email Ms. Orsolya Pulay at [email protected] with the list to determine if they are legal and/or available in Hungary. Some prescription medicines, like Adderall, have components that are illegal to bring to and possess in Hungary. It is important to contact your physician prior to departure to determine if an alternative medical prescription is available if your current medication will not be available or legal. Illegal medications will be confiscated by customs.
Additional Health Information or Special Accommodations*
BSM is committed to providing all participants with equal access and opportunity to our academic environment. Are there any circumstances relating to academic, housing, transportation or medical needs which require special accommodations? Provide details below.
Form Completion Verification*
I have completed this form honestly, accurately and fully.
- Yes