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Checklist for Full-Time Missionary Recommendation
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 To the Bishop or Branch President
Ensure that family members and others contributing to the Church's missionary funds are aware that contributions belong to the Church for use Review the Church Handbook of Instructions, Book 1: Stake Presidencies in its discretion to further missionary work and are not refundable even if and Bishoprics, and the First Presidency letters of 12 December 2000 and the missionary is unable to complete the full term of his or her mission.
11 December 2002 for information on qualifications, terms of service, On the Priesthood Leaders' Comments and Suggestions form, provide requirements for special clearance, and other instructions on calling pertinent information on the candidate' qualifications and abilities. Add comments on the candidate' experience, leadership capability, potential, The missionary recommendation packet for young missionaries should be interests, talents, or limitations that should be considered in determining submitted to the Missionary Department not more than 90 days before the the mission assignment.
candidate's availability date. Couples' packets may be submitted up to five The picture that accompanies the recommendation form should be current months in advance. The date given in the "Date available to serve" field and should show the candidate dressed and groomed according to should not be earlier than the birthday when the missionary reaches the minimum age for service. Normally about two to four months are allowed between the issuing of the call and the beginning of the mission.
Sign the Priesthood Leaders' Comments and Suggestions form and send
all required forms to the stake president. When you sign this form, you
If the candidate has been living away from home, the home bishop or are stating that in your opinion this individual is worthy to serve a
branch president and the away-from-home bishop or branch president mission. You are also confirming that you have reviewed the medical
must confer regarding worthiness and the procedures for submitting the information and conducted a thorough personal interview, which has
recommendation forms (see the Church Handbook of Instructions, Book convinced you that this person is physically and emotionally able to
serve a mission.
Conduct a thorough, searching interview with the candidate to determine Do not recommend members who are in debt and have not made definite worthiness, qualifications, and the individual's physical and emotional arrangements to meet their financial obligations.
capability to serve. Confirm that the candidate has an understanding and testimony of the Savior and His Atonement, the Restoration and Joseph To the Stake or Mission President
Smith' role in it, the Book of Mormon (having read it), and the singular privilege of serving the Savior as a missionary.
Review the Church Handbook of Instructions, Book 1: Stake Presidencies Give the candidate the missionary recommendation packet.
and Bishoprics, and the First Presidency letters of 12 December 2000 and 11 December 2002 for information on qualifications, terms of service, Review these forms after the candidate completes them. Ensure that any requirements for special clearance, and other instructions on calling serious concerns are resolved, including completion of recommended tests or treatment, before the forms are submitted. Give special attention to Conduct a thorough, searching interview. Confirm that the candidate has emotional, behavioral, and learning problems. If the candidate is on an understanding and testimony of the Savior and His Atonement, the medication for a chronic condition, encourage him or her to continue the Restoration and Joseph Smith's role in it, the Book of Mormon (having medication throughout the mission.
read it), and the singular privilege of serving the Savior as a missionary.
Conduct a final interview with the candidate before submitting the forms. Add your comments on the Priesthood Leaders' Comments and Make sure that all requested information has been provided, and fill in the Suggestions form.
Unit Information for Missionary Candidate form including the candidate's record number. Discuss with the candidate important information Make sure that all concerns have been resolved or adequately explained requested on the forms, such as visa or citizenship documentation and either on the Priesthood Leaders' Comments and Suggestions form or, if information about special medical problems, diets, or medications.
confidential, in a separate letter.
Ensure that after the contribution from the missionary and family, the ward Review all forms for accuracy and completeness.
or branch missionary fund can meet the financial obligation for the missionary.
Sign the Priesthood Leaders' Comments and Suggestions form, and send
all forms to the Missionary Department (at the address above). When you
For countries where supplemental financial support from the General sign this form, you are stating that in your opinion this individual is
Missionary Fund is authorized: If the candidate cannot be supported fully worthy to serve a mission. You are also confirming that you have
from personal, family, ward or branch, or stake or district funds, complete a reviewed the medical information and conducted a thorough
Request for Supplemental Financial Assistance for Full-Time Missionary personal interview, which has convinced you that this person is
form (31964), and send it to the area office with the missionary physically and emotionally able to serve a mission.
recommendation packet. Do not request assistance from the General Missionary Fund until the missionary, the family, and the ward or branch and stake or district have committed themselves to provide all the financial support they can.
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Full legal name (first) Date available to Home street address

City
State or province District (if any) Home phone (include area code) E-mail address (optional) Attach with tape one (1) photograph of the missionary candidate dressed and Other states, provinces, or countries where you have lived recently (or for extended periods) groomed according to missionary Address where your call should be sent, if different from home address

City
State or province District (if any) Phone (include area code) Confirmation date Current marital status Have you ever been Have ever been arrested (If yes to any of these, explain, including date of arrest, charge, and resolution.) Have ever had a police record Have ever been convicted of a crime Citizenship at birth Place of birth (city, state, or Current country of citizenship If dual citizenship, indicate second country of citizenship.
You have an official birth certificate Currently a documented citizen of your resident country (If no, indicate your current status in your country of residence.) Citizenship status imposes restrictions on traveling outside Nationalities of ancestors the country where you live You have a current passport Name (exactly as it appears on the passport) Father's full name Father is a member Father is deceased Father's birthplace (city, state, or province) Father's occupation Father's street address, if different from your home address

City
State or province District (if any) Home phone (include area code) E-mail address (optional) Check here if you do NOT want your father to be contacted at all. Missionary Recommendation
Your full legal name (first) Mother's full name Mother is a member Mother is deceased Mother's birthplace (city, state, or province) Mother's occupation Mother's street address, if different from your home address

City
State or province District (if any) Home phone (include area code) E-mail address (optional) Check here if you do NOT want your mother to be contacted at all. Residence and Caregiver Information
(relationship) If you do not live with both parents, please explain why.

Address of caregiver, if other than parents and different from home address

City
State or province District (if any) Home phone (include area code) E-mail address (optional) Check here if you do NOT want this person to be contacted at all. Other Family Members Who Have Served or Are Serving Missions
Father has served a mission (If yes, give name of mission.) Mother has served a mission (If yes, give name of mission.) Grandparents have served missions (If yes, give name of Relationship and location of immediate family members currently serving missions (parents, brother, sister, grandparents) Priesthood Leaders' Comments and Suggestions
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Missionary candidate's name (first) Final Evaluation (Items to be reviewed by priesthood leaders)
Check the following when they are complete: I have reviewed all forms completed by the candidate.
I have discussed and resolved my concerns, if any, with the candidate.
The candidate is worthy to hold a temple recommend.
The candidate is willing to serve where called and in any assignment that might be given.
Has the candidate lived outside your ward for any significant time in the last year? If yes, enter the date on which you conferred with the candidate's former bishop.
(School, Military, Employment, etc.) Bishop's or Branch President's Recommendation Provide information on the qualifications and abilities of the missionary candidate. Comment on the experience, leadership
capability, potential, interests, talents, or limitations of the candidate that should be considered in determining the mission assignment. Confidential comments should be discussed in a
separate letter.
Please evaluate the missionary candidate's leadership capability.
Bishop or Branch President's Confidential Comments
When you sign this form, you are stating that in your opinion this individual has a testimony of the gospel and is worthy and willing to serve a mission wherever called. You
are also confirming that you have reviewed the medical information and conducted a thorough personal interview, which has convinced you that this person is physically
and emotionally able to serve a mission.
Bishop or branch president's signature Telephone (include area code) Priesthood Leaders' Comments and Suggestions
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Missionary candidate's name (first) Check the following when they are complete: I have reviewed all forms completed by the candidate.
I have discussed and resolved my concerns, if any, with the candidate.
The candidate is worthy to hold a temple recommend.
The candidate is willing to serve where called and in any assignment that might be given.
Stake or Mission President's Recommendation Provide information on the qualifications and abilities of the missionary candidate. Comment on the experience, leadership capability,
potential, interests, talents, or limitations of the candidate that should be considered in determining the mission assignment. Confidential comments should be discussed in a separate
letter.
When you sign this form, you are stating that in your opinion this individual has a testimony of the gospel and is worthy and willing to serve a mission wherever called. You
are also confirming that you have reviewed the medical information and conducted a thorough personal interview, which has convinced you that this person is physically
and emotionally able to serve a mission.
Stake or Mission President's Confidential Comments
Stake or mission president's signature Telephone (include Area Code) If English is not the candidate's native language, have a native English speaker evaluate his or her English-speaking ability. The evaluators should use the following questions to interview the candidate and check the appropriate ranking, paying particular attention to the candidate' ability to use correct verb tenses, to answer appropriately, and to use sentences. What did you do to prepare for your mission? What will you do on your mission to ensure that you are successful? Tell me about your favorite scripture.
Key: Nonfunctional — Does not respond to questions.
Partially Functional — Has difficulty resonding to questions; does not use complete sentences or appropriate verb tense.
Functional — Responds appropriately to questions; uses complete sentences; generally uses proper verb tense.
Fluent — Understands and speaks with near-native ability; mostly uses proper verb tenses; responds confidently.
No English
Area Medical Advisor Review
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Missionary candidate's name (first) Area Medical Advisor Review Based on a review of the missionary candidate's history, the physician's health evaluation, and a review of laboratory findings, indicate the candidate's
ability to function at various levels of activity as a missionary.
Level A—No limitation Level B—Slight limitation Level C—Moderate limitation Level D—Marked limitation Level E—Not appropriate No limitation of activity in lifting, Slight limitation of activity; slight Moderate limitation of activity; Marked limitation of activity or has Conditions exist for which corrective carrying, walking 6 or more decrease of function or stamina, moderate decrease of function or special requirements, such as specific action has not been or cannot be miles per day, or spending 12 to such as problems with walking stamina; requires limited walking climate, use of wheelchair, frequent taken, such as severe chronic pain, 16 hours per day in missionary (limited to 3-6 miles per day) or with (0-3 miles per day) or sedentary rest periods, special medical needs, or loss of stamina, or recurring extensive standing. Selected Limitations Additional Comments Education and Service of Missionary Candidate
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Your full legal name (first) Number of years studied in the last 5 years (Complete this column for languages you do NOT speak natively.) Language you want your call letter to be printed in

Indicate how interested you are in learning a language.
Moderately interested Somewhat interested Rate how successful you feel you would be in learning a language for your mission.
Moderately successful Somewhat successful Not very successful Education and Work Experience
Highest education level achieved Graduated from high school Rate your performance at schoolwork Years in seminary Graduated from seminary Post-secondary education (such as bachelor's degree) Post-graduate education (such as master's degree, doctorate, and so on) Extracurricular activities, special skills, hobbies, and special accomplishments Previous Church callings and leadership experience Work experience outside the home (Include number of years in each job.) Office experience General bookkeeping Education and Service of Missionary Candidate
Your full legal name (first) State or province License has been suspended If yes, explain. (Give date and reason for suspension.) Current or previous military experience Name of military organization Member of military reserve unit (U.S. only) Name of reserve organization Reserve service number Name of commanding officer
Unit mailing address
State or province Source of Funds Indicate how much money (in your local currency) will be contributed per month in support of your mission from the sources below. Enter single combined amount for a
couple in "Self."
Local currency

Self
Candidate Comments Explain any special circumstances or situations that the Brethren should consider when making your mission call.
Unit Information for Missionary Candidate
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Missionary candidate's record number (provided by ward or branch) Unit Information Completed by bishop or branch president
Home ward or branch Home stake or mission Name of home bishop or branch president Name of home stake or mission president Mailing address (including country) Mailing address (including country) Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code) Unit Information for Unit Submitting Recommendation If other than home unit
Name of bishop or branch president Name of stake or mission president
Mailing address (including country)
Mailing address (including country) Home phone (area code) Work phone (area code) Cell phone (area code) Home phone (area code) Work phone (area code) Cell phone (area code) Instructions for Missionary Candidate
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 1. Complete all information on the Missionary Recommendation form. Have the physician complete the Physician's Health Evaluation of Type if possible, or print neatly in black ink. Write dates in day, month, Missionary Candidate form and mail it and the Personal Health History year format (15 Dec 2001).
of Missionary Candidate form to your bishop or branch president. Where mail is unreliable, personally retrieve the forms.
2. Complete the Education and Service of Missionary Candidate form. Fill out the Personal Health History of Missionary Candidate form 7. Begin the hepatitis A and B immunizations and boosters for diphtheria, completely, honestly, and accurately before your medical examination.
tetanus, measles, and mumps immediately. You will receive additional immunization information with your mission call.
3. Sign the "Authorization to Release Information" section on the Physician's Health Evaluation of Missionary Candidate form.
8. Obtain a thorough dental examination. Begin early. Sign the "Authorization to Release Information" section on the Dental Evaluation 4. If you have had any major illness, major operation, major injury, for Missionary Candidate form, and give the form to the dentist along prolonged treatment, or hospitalization, obtain a statement from the with a stamped envelope addressed to your bishop or branch professional who treated you, if possible, to explain the nature of the president. Have the dentist fill out the form and mail it to your bishop or problem and its current status. It is important that you provide complete branch president. Where mail is unreliable, personally retrieve the information about your physical condition. For example, it is not enough to say that you had a knee injury; you must also state which knee was injured and explain whether there are any persistent problems with the 9. Have all dental work, including orthodontic work, completed before submitting the missionary recommendation packet to your bishop or branch president.
5. The Physician's Health Evaluation of Missionary Candidate form must be signed by a medical doctor (MD) or doctor of osteopathy (DO). If the 10. You are expected to be physically and emotionally capable of working examination is done by a physician assistant (PA) or nurse practitioner several hours a day. For young missionaries, this means walking (NP), the supervising physician must verify the findings and review and several miles a day six days a week. If there are reasons why this countersign the form. An examination by any other practitioner is not might not be possible, please discuss them with your bishop or branch 6. Give the following forms to the physician along with a stamped envelope 11. Before entering the MTC, correct any problems such as plantar warts, addressed to your bishop or branch president: flat feet, chronic headaches, inguinal hernias, and so on. Stabilize and The completed Personal Health History of Missionary Candidate understand the treatment for chronic problems such as asthma, diabetes, seizures, emotional disorders, irritable bowel, endometriosis, and so on.
The Instructions for Physicians Evaluating Missionary Candidates.
12. If you are taking prescribed medication for any chronic problem, The Physician's Health Evaluation of Missionary Candidate form.
medical or emotional, do not stop taking it unless your physician advises you to do so. Please list on the Personal Health History of Missionary Candidate form all medications you are currently taking.
13. Complete all appropriate sections of the Personal Insurance Information of Missionary Candidate form.
Instructions for Parents of Young Missionaries
5. Pay particular attention to item 11 above. This will help avoid unnecessary problems and expenses in the MTC or the mission field.
1. Review the completed forms, and add any pertinent information.
6. If you have private insurance coverage for your son or daughter, do not 2. Please make sure that the instructions under item 3 above are carried out discontinue it. Please note it on the Personal Insurance Information of and that clarifying statements are submitted with the Personal Health Missionary Candidate form with pertinent data.
History of Missionary Candidate form. Failure to do so may delay the mission call unnecessarily.
7. During the mission, a missionary's family must bear the costs of caring for preexisting medical conditions. A preexisting condition is any chronic, 3. Encourage your son or daughter to continue to take any prescribed congenital, or medical condition with signs or symptoms, a diagnosis, or medications. Problems may arise when missionary candidates stop taking treatment within two years before the missionary enters the mission field, medication because they believe that being on medication might affect the regardless of whether the symptoms are present when the missionary missionary assignment they receive.
enters the field.
4. Please make sure your son or daughter gets thorough medical and dental All donations to the Church's missionary funds become the property of the examinations. The Church is greatly concerned about the health and safety Church to be used at the Church' sole discretion in its missionary programs. of the missionaries. The purpose of a careful medical evaluation is to Contributions are not refundable, including any advance contributions, if the ensure that missionaries can handle the rigors of missionary work and missionary is unable to complete the full term of the mission. receive assignments in which they can succeed. Missionaries are exposed to many physical, environmental, social, and emotional stresses, often in areas where there is minimal medical care. It is unfortunate when a missionary must return home early because of problems that could have been avoided or stabilized before the mission.
Personal Health History of Missionary Candidate
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Please answer all of the following questions. Be honest with yourself, your physician, and the Lord. Major difficulties may result if this information is not complete and accurate. Please do not withhold or deny any medical information.
Your full legal name (first) Key: Current = is currently occurring; Previous = occurred previously, but is now resolved; Never = has never occurred
Persisting difficulties from serious injury or deformity of your head or other body parts Sight impairment, glaucoma, or cataracts (need for glasses or contacts; chronic eye infection) Problems with hearing normal conversation (require a hearing aid) Recurrent sinusitis, sore throat, ear infections, or nasal obstruction Lung disease, emphysema, tuberculosis, shortness of breath, spitting or coughing up blood or colored sputum, or collapsed lung Hay fever or allergies High blood pressure, irregular heart rhythm, heart pain, coronary artery disease, congenital heart disease, or cardiomyopathy Varicose veins or thrombophlebitis Heartburn, reflux, ulcers, irritable bowel, chronic diarrhea, rectal bleeding, ulcerative colitis, or Crohn's disease Gall bladder disease or stones, hepatitis, or cirrhosis or other liver problems Rupture (hernia), varicocele, or varices Hypoglycemic attacks Thyroid or other hormonal problems or unexplained weight loss Kidney or urinary difficulties Kidney or urinary disease or stones, repeated urinary infections, burning or frequent urination, or difficulty urinating Incontinence or enuresis (bed wetting) Sexually transmitted disease Chronic skin sores, rashes, warts on feet, changing moles, lumps, or swelling Acne requiring Accutane Sensitivity to the sun Back or neck injury, arthritis in back or neck, spondylitis, chronic back or neck pain, or difficulty lifting things Upper extremity—loss of any part or deformity, paralysis, joint pain, arthritis, or other problem in: Other upper extremity Personal Health History of Missionary Candidate
Your full legal name (first) Lower extremity—loss of any part or deformity, paralysis, joint pain, arthritis, or other problem in: Other lower extremity (such as ingrown toenails) Frequent or severe headaches: Migraine headaches Tension headaches Frequent mild headaches Unconsciousness from head injury or interference with coordination or skilled movements; weakness or sensory loss from illnesses such as Parkinson's disease, multiple sclerosis, stroke, and so on Fainting, dizziness, convulsions, seizures, or hyperventilation Frequent feelings of being sick or easily tired, anemia, or bleeding tendency Chronic fatigue syndrome or fibromyalgia syndrome Insomnia or difficulty sleeping Tumors, cancers, leukemia, chemotherapy, radiation therapy, or organ transplantation Reaction or allergy to drug or medication Taking medications (prescriptions, over the counter drugs, or vitamins and supplements) Other diseases or problems with your physical health not already noted, including family history of tuberculosis or other disease Surgery, hospitalization, or injuries not listed above Learning difficulties: Pervasive developmental disorder (Asperger's disorder, autism) Other learning disorders (including speech disorders) Emotional difficulties: Separation anxiety (homesickness) Other changing moods, anxieties, nervousness, or depressions Personal Health History of Missionary Candidate
Your full legal name (first) Difficulty in relationships due to temper, moods, or habits (fights or aggressive behavior) Schizophrenia or psychosis Eating disorders—anorexia, bulimia, or obesity Abuse of or dependency on prescription or over-the-counter medications, recreational drugs, or alcohol Been a victim of physical, sexual, or emotional abuse Undiagnosed aches and pains Counseling, treatment, or hospitalization for emotional problems Other emotional problems Endometriosis, painful menstruation, abnormal vaginal discharge, uterine or ovarian tumors or cysts Can work 12 to 15 hours per day, walk 6 to 8 miles per day, ride a bicycle 10 to 15 miles per day, and climb stairs daily Will receive immunizations Delcaration and Authorization by Missionary Candidate
I declare that the statements made in the Personal Health History of Missionary Candidate are a complete and honest report of my health history. No personal health information has been withheld or misrepresented. I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other countries for Church purposes my personal data, including explicit sensitive data, in accordance with the Church Data Privacy Policy.
Missionary candidate's signature Parent or guardian's signature Instructions for Physicians Evaluating Missionary Candidates
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Missionaries for The Church of Jesus Christ of Latter-day Saints 4. Stabilize chronic problems such as asthma, diabetes, seizures, serve in various environments and cultures throughout the world. emotional disorders, irritable bowel, endometriosis, and so on. They are normally expected to engage in missionary activities many Carefully instruct the candidate on the treatment for these hours per day, including walking many miles a day, six days a week. problems, and explain personal care under diverse circumstances. The rigors of a mission usually exacerbate any prior difficulties. Also explain the importance of continuing to take any prescribed Please use the following guidelines in examining the missionary 5. Do not sign the Physician's Health Evaluation of Missionary 1. The Physician's Health Evaluation of Missionary Candidate form Candidate form without reviewing the Personal Health History of must be signed by a medical doctor (MD) or doctor of osteopathy Missionary Candidate form with the candidate. Please comment (DO). If the examination is done by a physician assistant (PA) or on each abnormality listed by the candidate.
nurse practitioner (NP), the supervising physician must verify the findings and review and countersign the form. An examination by 6. When a major illness, operation, injury, hospitalization, or any other practitioner is not acceptable.
prolonged treatment is mentioned, please obtain a summary report of the incident from the professional who treated the case. This 2. Please perform a thorough physical examination to ensure that report should accompany the candidate's application.
missionaries receive assignments in which they can succeed. It is unfortunate when a missionary must return home early because of 7. Obtain necessary consultations to clarify the candidate's ability to problems that could have been avoided or stabilized before the function in the mission field as well as his or her current physical and emotional status where advisable.
3. Correct any problems such as plantar warts, flat feet, chronic 8. Complete all specified laboratory tests. Everyone, including those headaches, or inguinal hernias before the missionary candidate who have had BCG vaccine or a chest X ray, should have a PPD leaves for his or her mission. Explain to the candidate any skin test. Only those already known to be positive are exempted.
problems that do not need correcting, such as a deviated nasal 9. Please mark the appropriate box indicating the candidate's overall septum, varicocele, pilonidal disease, and so on, in case a ability to function in the mission field on the "Missionary Fitness physician in his or her mission insists that such a condition must Report: Overall Assessment of Functional Ability." be surgically corrected.
Physician's Health Evaluation
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 To the physician: Please type, print, or write legibly in black ink when completing this form. Attach additional information if necessary. When
you have completed the form, mail it and a copy of the Personal Health History of Missionary Candidate form directly to the candidate's bishop
or branch president, using the envelope provided by the candidate. Your thorough evaluation and completion of all requested forms, information,
and recommendations will be greatly appreciated. Where mail is unreliable, give the forms in a sealed envelope to the missionary candidate.
Missionary candidate's name (first) Height (in inches or centimeters) Weight (in pounds or kilograms) Vision (with corrective lenses, if required) /
General appearance If abnormal, give specific details and indicate functional capacity (referring to item number). Ears (audiogram and balance if necessary) Nose, throat, neck, and thyroid Heart and blood vessels (murmurs) Abdomen (masses, liver, and spleen) 1. Rectal area, varicocele, and hernia Back (history of pain, disability, treatment; also pilonidal disease) Upper extremities Lower extremities Neurological system (Women only) breasts (Women only) pelvic area, including Pap test (if over 40 or indicated by history) Comment on abnormalities noted in history or physical exam regarding: 16.1. Epilepsy16.2. General medical problems16.3. Surgical problems16.4. Learning, memory, or communication disorders16.5. Emotional, psychological, or psychiatric disorders16.6. Abuse of prescription medicines, illegal drugs, or alcohol16.7. Consultations requested Urinalysis (tests for specific gravity, protein and sugar are all required) Specific gravity (required) Microscopic (if protein abnormal) Hemoglobin or hematocrit (circle the type and enter the test result) Type Rh factor PSA (males over 50) Physician's Health Evaluation
Missionary candidate's name (first) Mammogram (within last year for females over 40) If abnormal, please give specific details and indicate functional capacity (referring to item number). 22 Tuberculosis testing (PPD-10TU)—required for all (including those who had BCG vaccine and those who are known to be positive) Millimeters of induration (required) (If 10 or greater, chest X ray required) Chest X ray taken INH is prescribed If INH is prescribed for a PPD converter, treatment should be started as soon as possible. If active disease is found, missionary service must be delayed until treatment is completed. If prescribed, date when treatment will be completed: Immunization Dates

Tetanus/diphtheria
Hepatitis A #1 AND hepatitis B #1 OR combined hepatitis A and B #1 #2 Missionary Fitness Report: Overall Assessment of Functional Ability Based on a review of the missionary candidate's history, your personal interview, a physical examination, and
a review of laboratory findings, indicate the candidate' ability to function at various levels of activity as a missionary below.
Level A—No limitation Level B—Slight limitation Level C—Moderate limitation Level D—Marked limitation Level E—Not appropriate No limitation of activity in lifting, Slight limitation of activity; slight Moderate limitation of activity; Marked limitation of activity or has Conditions exist for which carrying, walking 6 or more miles decrease of function or stamina, moderate decrease of function or special requirements, such as corrective action has not been or per day, or spending 12 to 16 hours such as problems with walking stamina; requires limited walking specific climate, use of wheelchair, cannot be taken, such as severe per day in missionary activity.
(limited to 3-6 miles per day) or with (0-3 miles per day) or sedentary frequent rest periods, special chronic pain, loss of stamina, or extensive standing.
medical needs, or medical visits.
Additional comments Physician's signature Name of physician The exam was performed within the last 12 months. Physician's office address State or province District (if any) Office phone (with area code) E-mail address (if available) Authorization to Release Information
I authorize the examining physician to release the information contained in the Personal Health History of Missionary Candidate and the Physician's Health Evaluation of Missionary Candidate to my bishop or branch president and the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by physicians. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the examining physician from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of Latter-day Saints or its agents.
Missionary candidate's signature Witness's signature Dental Evaluation for Missionary Candidate
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Missionary candidate's name (first) To the priesthood leaders:
3. Your dentist will retain this evaluation form, and will not send it to your bishop or branch president until all needed dental treatment, including active orthodontic treatment, has 1. All dental treatment, including active orthodontic treatment, must be completed before a prospective missionary begins missionary service. To the examining dentist:
2. Active orthodontic treatment is defined as any one of the following: a. Bonded or banded braces on the teeth. 1. As you evaluate this missionary candidate's dental condition, please be aware that b. Invisalign treatment trays. he/she might be assigned to serve for two years in an area of the world with limited or c. Removable appliances requiring periodic adjustments. inadequate professional dental care. Third molar complications are the most common medical-dental problem in the mission field today. 3. Wearing a final retainer appliance after active orthodontic treatment is completed is not considered active treatment. 2. Please help this candidate understand the role of plaque in dental disease and the importance of daily personal oral hygiene to maintain dental health. Please correct To the missionary candidate:
overhangs and rough interproximals that would make flossing difficult or impossible. 1. Have your dental examination early (6 months) to allow plenty of time to complete all 3. The missionary candidate will give you a stamped envelope addressed to his/her bishop dental treatment, including active orthodontic treatment. Your application will not be or branch president. When you are satisfied that all treatment has been completed or processed until all necessary treatment has been completed or scheduled. scheduled, mail this form to the missionary's bishop or branch president. Where mail is unreliable, give the form in a sealed envelope to the missionary candidate.
2. Give your dentist a stamped envelope addressed to your bishop or branch president.
Has the missionary candidate had a complete oral examination with bite wing x-rays within the last six months? Has a full-mouth set of x-rays or panoramic x-ray been taken within last twelve months? Have all third molars that were likely to become problematic during the next two years been extracted? Has all dental decay and gum infection been resolved? If this candidate has undergone orthodontic treatment, has active treatment been completed at this time? Do you believe this candidate will be free of dental problems during the next two years if proper daily personal oral hygiene is practiced? Dentist's signature Dentist's office address State or province District (if any) Office phone (with area code) E-mail address (if available) Authorization to Release Information
I authorize the examining dentist to release the information contained in this dental evaluation to my bishop or branch president and the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by dentists. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the examining dentist from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of Latter-day Saints or its agents.
Missionary candidate's signature Witness' signature Personal Insurance Information of Missionary Candidate
MISSIONARY DEPARTMENT50 E NORTH TEMPLE ST RM 345 WSALT LAKE CITY UT 84150-5400 Your full legal name (first) You have a medical insurance provider If yes, please give your Social Security number If yes, indicate whether you will be covered by a group or individual health insurance plan while serving your mission.
Insurance Company Information
Name of primary insurance company

Policyholder's name
Policyholder's Social Security number Policyholder's date of birth Effective date of coverage This coverage will terminate while you are serving as a If yes, give termination date (day, month, year).
Policyholder's ID number Mailing address for submitting claims State or province District (if any) Phone number of insurance company (include area code) Indicate where this insurance plan will provide benefits for services incurred while you are serving as a missionary. (Check all that apply.) At your current location and within your state or province Emergency coverage only If full coverage, indicate what additional benefits are provided by your plan and which of them require prior authorization. (Check all that apply.) Provided Prior authorization required Hospitalization (inpatient or outpatient) Medical (physician visits, lab, X ray) Prescription drugs Emotional illness (psychotherapy) Outside your state or province but still within your country Emergency coverage only If full coverage, indicate what additional benefits are provided by your plan and which of them require prior authorization. (Check all that apply.) Provided Prior authorization required Hospitalization (inpatient or outpatient) Medical (physician visits, lab, X ray) Prescription drugs Emotional illness (psychotherapy) Outside your country Emergency coverage only Personal Insurance Information of Missionary Candidate
Your full legal name (first) If full coverage, indicate what additional benefits are provided by your plan and which of them require prior authorization. (Check all that apply.) Provided Prior authorization required Hospitalization (inpatient or outpatient) Medical (physician visits, lab, X ray) Prescription drugs Emotional illness (psychotherapy) This health plan has an annual deductible that must be met before benefits are If yes, indicate the amount (in U.S. dollars).
You have coverage from another insurance company If yes, indicate whether you will be covered by a group or individual health insurance plan while serving your mission.
Authorization for Release of Information—Young Missionary
I authorize any physician, medical practitioner, hospital, clinic, other health care provider, or insurance company to disclose to The Church of Jesus Christ of Latter-day Saints or its representatives and affiliated entities all information and records with respect to any claim, physical or mental condition, treatment, or medical history, and evaluation thereof. I understand that if I become sick or injured during my mission, the Church will provide initial payment for my medical expenses, except for pre-mission conditions, but payment by the Church is not intended to replace my personal insurance. I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other countries for Church purposes my personal data, including explicit sensitive data, in accordance with the Church Data Privacy Policy.
Missionary candidate's signature Authorization for Recovery from Provider—Parents of Young Missionary
By signing below, I hereby authorize and request that The Church of Jesus Christ of Latter-day Saints be reimbursed for all amounts paid to providers, which amounts are the primary obligation of the above-named insurance companies, and I authorize the Church to undertake all appropriate measures to recover said amounts. Parent or guardian's signature Your full legal name (first) I hereby authorize The Church of Jesus Christ of Latter-day Saints, its officers, affiliated entities and departments (collectively the "Church"), to process my personal data for purposes relating to a missionary calling in the Church. This authorization includes the following understandings and consents: The Church will have access to my personal and sensitive data for the purposes of evaluating my missionary application, determining my missionary assignment if my application is accepted and overseeing my mission. I consent that the Church may process my personal and sensitive data for these purposes. I have informed my parents and/or caregivers that I will include some of their personal data in my missionary application. My Bishop and Stake President (or Branch President, District President and Mission President, as the case may be) will provide evaluations of my qualifications to serve as a missionary. I agree that these evaluations are related to determining my worthiness and capacity to serve as a missionary. I understand that these evaluations are strictly confidential and I hereby waive any right of access to these evaluations. The provision of my personal data is necessary in order for the Church to process my missionary application. I authorize the transfer of my personal data, including sensitive data relating to my ethnic origin, religious beliefs, physical and emotional health, and any criminal history, to Church headquarters in the State of Utah, United States of America and to other countries with less stringent data protection laws than the country in which I reside. I understand and acknowledge that the transfer of this information is necessary for the Church to evaluate my application to serve the Church as a missionary. With the exception of ecclesiastical leaders' evaluations, I may access, upon my written request, the personal data I have provided in connection with this missionary application and I may rectify any erroneous data. The Church will retain my personal data during my mission. Although some data will be destroyed after completion of my mission, other data may be retained indefinitely as part of the historical or other records of the Church. I authorize the Church to use and retain my data in its discretion. Should I have questions concerning the protection of my personal data or the security of personal data processed by the Church, I have been advised that I may communicate my questions to the Church's representative for data privacy at [email protected]. I understand that all donations to the Church's missionary funds become the property of the Church to be used at the Church's sole discretion in
its missionary program and are not refundable.
Medical Privacy Notice

Deseret Mutual Benefit Administrators ("Deseret Mutual"), through its Missionary Medical Division, helps to coordinate and administer missionary
health care. Deseret Mutual is a not for profit Church-affiliated entity that has been assigned by the Church's Missionary Department. The United
States government has enacted new privacy laws and regulations with which Deseret Mutual must comply. One of the requirements is to provide
you with a Medical Privacy Notice explaining how your health information will be used and disclosed.
1. Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other health-care provider, a record of your visit is made. Typically, this record contains your
symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. It may also contain correspondence and
other administrative documents.
Protected health information (or "PHI") is any personally identifying information which when linked to health data could be used to identify an
individual. This information may be stored or transmitted in any form (for example, paper, electronic, verbal, etc.). All of this information, often
referred to as your health or medical records, serve as a:
• Basis for planning your care and treatment
• Means of communication among the many health professionals who contribute to your care
• Legal document describing the care you received
• Means by which you or a third-party payer can verify that services billed were actually provided
• Tool in educating health professionals
• Source of data for medical research
• Source of information for public health officials charged with improving the health of the nation
• Source of data for facility planning
• Tool to assess and monitor the health care being provided and the outcomes achieved
2. Your Health information Rights
With respect to that portion of your health record held by Deseret Mutual, you have the right to:
• Inspect and obtain a copy of your health record
• Amend your health record
• Request a restriction on certain uses and disclosures of your information
• Obtain an accounting of disclosures of your health information (other than for purposes of treatment, payment, and health care operations)
• Request communications of your health information by alternative means or at alternative locations
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken
3. Our Responsibilities
Deseret Mutual is required to:
• Maintain the privacy of your health information
• Provide you with notice of our legal duties and privacy practices regarding information we collect and maintain about you
• Abide by the terms of this notice
• Notify you if we are unable to agree to a requested restriction
• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations
We will not use or disclose your PHI without your authorization, except for treatment, payment or health-care operations, or as provided by law.
We reserve the right to change our practices and make the new provisions effective for all PHI we maintain. If we do so, we will notify you of the
changes in writing.
4. For More Information or to Report a Problem
If you have any questions or if you would like additional information, you may contact Deseret Mutual's Compliance Specialist or Compliance
Officer by telephone (1-801-578-5600 or 1-800-777-3622), by mail (60 East South Temple, Salt Lake City, UT 84111, USA) or by fax (1-801-
578-5906).
If you believe your privacy rights have been violated, you can file a complaint with Deseret Mutual's Compliance Specialist or Compliance
Officer, or with the United States Department of Health and Human Services, Office for Civil Rights (OCR). Complaints must be in writing and
can be filed either by mail or electronically. OCR will provide further information on its Web site about how to file a complaint
(www.hhs.gov/ocr/hipaa/). Please note that there will be no retaliation for filing a complaint.
5. Uses or Disclosures for Treatment, Payment, and Health Care Operations
• Treatment, Payment, and Health Operations: We may use your health information for treatment, payment, and health care operations. For
example, with respect to treatment, information obtained by a nurse, physician, or other member of your health care team will be recorded in
your record and used to determine the course of treatment that should work best for you. With respect to payment, a bill may be sent to you or a
third party payer. With respect to health care operations, we may use your health care information to study ways to improve utilization or reduce
health care costs.
6. Uses or Disclosures Permitted or Required by Law
• To you, the individual.
• United States Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to
food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
• Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease,
injury, or disability.
• Correctional Institution: If you become an inmate of a correctional institution, we may disclose to the institution or agents thereof PHI necessary
for your health and for the health and safety of others.
• Law Enforcement or Judicial Proceedings: We may disclose certain PHI for law enforcement purposes as required by law or in response to
valid subpoena.
Authorization to Use and Disclose Protected Health Information and Authorization to Use and Disclose Psychotherapy Notes

I hereby authorize the Church and its affiliated entities to disclose the personal health information collected through the Missionary
Recommendation Form as described in the Notice of Privacy Practices for Protected Health Information.
Deseret Mutual may disclose my protected health information to my local unit priesthood leaders (such as the bishop and stake president),
employees of the Missionary Department, medical professionals who act as volunteers in the Missionary Department, personnel at the
Missionary Training Center and BYU Student Health Center, and your mission representatives (such as your mission president).
My protected health information may also be disclosed to one or more clerks who assist my local unit priesthood leaders (such as the ward and
stake clerks), and to others I identified specifically by name (such as my parents), except as I have noted to restrict contact with one or more
persons. My protected health information may be disclosed to assist in treatment of an illness or injury and to assist in determining pre-mission
conditions that may impact payment of treatment and the recovery of costs.
These authorizations of disclosure will expire one year (1) after my missionary service is terminated. I understand that once my protected health
information has been disclosed according to this agreement and in accordance with the Notice of Privacy Practices for Protected Health
Information, the recipient of my information may disclose my information to others and will no longer be protected.
The use and disclosure of protected health information authorized herein is for the purpose of the overall management and administration of my
health care while a missionary for The Church of Jesus Christ of Latter-day Saints so that I can be an effective missionary on behalf of, and
serve the needs of, the Church.
Insurance and Medical Expense Acknowledgement
The Church Handbook of Instructions indicates all missionaries are strongly encouraged to maintain their existing medical insurance during their
missions. This conserves Church funds and helps missionaries avoid having to prove insurability after their missions. Maintaining coverage
helps provide protection for past chronic or congenital problems and post-mission medical needs. This directive is consistent with the principles
of self-reliance and self-sufficiency.
Couples and single sisters ages 40 and over are responsible for their own health care expenses and must have health insurance adequate for
their mission assignments. If the insurance coverage of those living away from home is not adequate for their assignment, Deseret Mutual will
send them information on additional insurance that they may purchase. Missionaries who need additional coverage but do not enroll in the
DMBA plan must provide proof of adequate coverage before their service begins.
Acknowledgement:
I understand that if I become sick or injured during my mission, the Church may provide initial payments for my medical expenses except for pre-
mission conditions. Payments in the United States will be made through Missionary Medical, a Division of Deseret Mutual, a not for profit Church
affiliated entity.
These payments are made from the general funds of the Church and are gratuitous and voluntary in nature. Payments are not made from a
Church insurance policy and are not intended to replace my personal health insurance.
I understand that claims will be filed with my insurance carrier. I agree to support all recovery efforts (including assisting in claims filing and
reimbursement procedures) in the event the Church makes initial payment for medical expenses. I agree to support efforts by Missionary
Medical to coordinate care directly with my parents (when authorized for disclosure), healthcare providers, and my insurance carrier.
I understand that if I am involved in an accident that the Church neither encourages nor discourages legal action from potentially liable or
responsible third parties. I agree to reimburse the Church for medical expenses paid on my behalf in the event a settlement is reached or when a
liable party makes payments.
I authorize the release of my medical information to the following individuals:
Name Relationship Personal Health Information Candidate's Signature

Source: http://www.ctfp.com/Missionary_Papers.pdf