W2N Doctor Portal

Form Sections

1

Participant Information

Completed by participant

2

Doctor Evaluation

Your section

3

Specialist Evaluation

If required

Section 1: Participant Information

Loading participant information...

Section 2: Doctor Evaluation

Blood Pressure

Heart Rate (bpm)

Temperature (°F)

Weight (lbs)

General Health Assessment

Current Medications

Allergies

Travel Restrictions or Concerns

Specialist evaluation required

Check this if the participant needs additional specialist clearance

Medical Clearance for Travel

✅ Approved - Medically cleared for travel ⚠️ Conditional - Approved with conditions (specify below) ❌ Not Approved - Not cleared for travel

Additional Notes

Doctor Name

License Number

Medical Facility

Contact Phone

Mental Status Examination

Cognitive Function

Insight and Judgment

Current Mental Health Diagnosis

Current Psychiatric Medications

Treatment History

Risk Assessment

Suicide Risk

Low Moderate High

Self-Harm Risk

Low Moderate High

Stress Management and Coping Skills

Social Support System

Travel-Specific Mental Health Concerns

Mental Health Clearance for Travel

✅ Approved - Mentally and emotionally cleared for travel ⚠️ Conditional - Approved with mental health support plan (specify below) ❌ Not Approved - Not cleared for travel at this time

Recommendations and Support Plan

Specialist Name

License Number

Practice/Facility

Contact Phone

Doctor Portal

Important Information

Form Sections

Section 1: Participant Information

Section 2: Doctor Evaluation