UMC Form 103 2025 - Fill, Sign Online, Download & Print - No Signup
Form 103
Page 1 of 6
Revised 1/2025
MEDICAL SUMMARY REPORT OF MINISTERIAL CANDIDATE
Candidate’s Name:
To Candidate: Please fill out page one of this form and take with you to your doctor to fill-out page 2.
Scan and upload completed form to ebridge.
CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION
Candidate Name:
Birth Date:
I hereby authorize and direct
(physician) to disclose to
the Indiana Conference Board of Ordained Ministry the following information with regard to the
records of
(candidate) for the purpose of evaluation by The
United Methodist Church for entrance into ministry.
Release: I hereby release, indemnify, and hold harmless the (annual conference) Board of Ordained
Ministry from any legal responsibility or liability for the disclosure of the above information to the extent
indicated and authorized herein. This release includes any and all claims, damages, liabilities, or costs
that may arise from the use or disclosure of the information provided.
Voluntary Consent: I have read and fully understand this consent form and the purpose for which my
medical records will be used. My consent is voluntary. I acknowledge that I am not under any pressure
or duress to provide this consent.
I, the undersigned, understand that I may revoke this consent at any time except to the extent that
action has been taken in reliance upon it. This consent will expire sixty (60) days after the date
treatment is terminated unless another date is specified.
I understand that the information requested may be disclosed from records whose confidentiality is
otherwise protected by federal as well as state law. Any of the above requested information may
include results of alcohol/drug (substance) abuse and/or diagnosis and treatment of psychological
disorders, as well as HIV status.
To the party receiving this information: This information has been disclosed to you from records whose
confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from
making any further disclosure of it without the specific written consent of the person to whom it
pertains, or as otherwise permitted by such regulations. A general authorization for the release of
medical or other information is not sufficient for this purpose.
Form 103
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Revised 1/2025
Signature of Candidate
Date
Witness
Date
SIGN
Form 103
Page 3 of 6
Revised 1/2025
SUMMARY REPORT – COMPLETED BY PHYSICIAN
Comments for physician:
Complete the summary report. The United Methodist Church assumes you are completing this
information based on a current physical examination of the candidate. Screening guidelines are
provided for reference as needed.
This person is a candidate for ministry in The United Methodist Church. Among other requirements,
this includes being able to typically work a full-time week – with periodic weeks requiring longer work
hours. Those serving in ministry will encounter situations that require the ability to cope with conflict
and stress. Job-related tasks range from office work and traveling from site to site to communicating
with and relating to a variety of people and managing multiple tasks simultaneously, among other
responsibilities.
Candidate’s Name:
Date of Physical Exam:
Check One:
☐
Based on the physical exam I completed, this candidate appears to be healthy. I have no
concerns about his/her physical fitness for ministry.
☐
Based on the physical exam I completed, this candidate has some health concerns that are
summarized below.
Summary of Concerns:
Typical treatment(s) for this condition could potentially include (medication, surgery, lifestyle
modification, intervention by specialist, frequent monitoring, etc.):
Form 103
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Revised 1/2025
Questions to ask, or conversations that a committee might have, to address these concerns could
include:
Examining Provider: ________________________________________________________________
Address: __________________________________________________________________________
_________________________________________________________________________________
Phone: ___________________________________________________________________________
Fax: _____________________________________________________________________________
______________________________________________
_____________________________
Signature:
Date:
STAMP
SIGN
Form 103
Page 5 of 6
Revised 1/2025
EXAMINATION STANDARDS*
As a part of the ministry application process, The United Methodist Church requires each candidate to
“present a satisfactory certificate of good health” by a physician on the prescribed form. Disabilities are
not to be construed as unfavorable health factors when a person with disability is capable of meeting the
professional standards and is able to render effective service…. (The Book of Discipline, ¶¶ 315.6c, 324.8,
347.3, 357.7, 355.3, 368.5). *Based on recommendations from the U.S. Preventive Services Task Force.
The following lists show standard screening practices to be considered in an assessment of physical
health. Additionally, the physician may choose to make recommendations to the candidate as needed.
While the candidate’s physician should make the final determination regarding the need for specific
medical tests as related to the overall health and needs of the candidate, The United Methodist Church
seeks a summary report from the physician upon completion of a physical examination of the candidate
that provides an assessment of the candidate’s physical ability to perform the required work of ministry.
NOTE: DO NOT RECORD SCREENING RESULTS ON THIS FORM.
Screening
•
Height and weight (periodically) Blood pressure
•
Alcohol and tobacco use
•
Depression (if appropriate follow‐up is available) Diabetes mellitus (patients with hypertension)
•
Dyslipidemia (total and HDL cholesterol): men ≥35 y; men or women ≥20 y who have
cardiovascular risk factors; measure every 5 y if normal
•
Colorectal cancer screening (men and women 50‐75 y)
•
Mammogram every 1 to 2 y for all women ≥40 y. Evaluation for BRCA testing in high‐risk women
only.
•
Papanicolaou test (at least every 3 y until age 65 y)
•
Chlamydial infection (sexually active women ≤25 y and older at‐risk women) Routine voluntary HIV
screening (ages 13‐64 y)
•
Bone mineral density test (women ≥65 y and at‐risk women 60‐64 y) AAA screening (one time in
men 65‐75 y who have ever smoked)
Counseling—Substance Abuse
•
Tobacco cessation counseling
•
Alcohol misuse: brief behavioral counseling; alcohol abuse: referral for specialty treatment
Counseling—Diet and Exercise
•
Behavioral dietary counseling in patients with hyperlipidemia, risks for CHD and other diet‐related
chronic disease
•
Regular physical activity (at least 30 minutes per day, most days of the week)
•
Intensive counseling/behavioral interventions for obese patients
AAA = abdominal aortic aneurysm; BRCA = breast cancer susceptibility gene; CHD = coronary heart
disease.
Form 103
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Revised 1/2025
Key Points
•
The U.S. Preventive Services Task Force recommends routine periodic screening for hypertension,
obesity, dyslipidemia (men ≥35 years), osteoporosis (women ≥65 years), abdominal aortic
aneurysm (one‐time‐screening), depression, and HIV infection.
•
The U.S. Preventive Services Task Force recommends routine periodic screening for colorectal
cancer (persons 50‐74 years of age), breast cancer (women ≥40 years), and cervical cancer.
•
The U.S. Preventive Services Task Force recommends that all pregnant women be screened for
asymptomatic bacteriuria, iron‐deficiency anemia, hepatitis B virus, and syphilis.
•
The U.S. Preventive Services Task Force recommends against screening for hemochromatosis;
carotid artery stenosis; coronary artery disease; herpes simplex virus; or testicular, ovarian,
pancreatic, or bladder cancer.
•
Outside of prenatal, preconception, and newborn care, genetic testing should not be performed in
unselected populations because of lower clinical validity; potential for false positives; and
potential for harm, including “genetic labeling.”
•
For patients for whom genetic testing may be appropriate, referral for genetic counseling should
be provided before and after testing.
•
A human papillomavirus vaccine series is indicated in females ages 9 through 26 years, regardless
of sexual activity, for prevention of cervical cancer.
•
A single dose of tetanus‐diphtheria–acellular pertussis (Tdap) vaccine should be given to adults
ages 19 through 64 years to replace the next tetanus‐diphtheria toxoid (Td) booster.
•
A zoster (shingles) vaccine is given to all patients 60 years and older regardless of history of prior
shingles or varicella infection.
•
Asymptomatic adults who plan to be physically active at the recommended levels do not need to
consult with a physician prior to beginning exercise unless they have a specific medical question.
•
Smoking status should be determined for all patients.
•
Patients who want to quit smoking should be offered pharmacologic therapy in addition to
counseling, including telephone quit lines.
•
Routine screening is recommended to identify persons whose alcohol use puts them at risk.
•
For management of alcohol abuse and dependence, referral for specialty treatment is
recommended; for management of alcohol misuse, brief behavioral counseling may be useful.
•
Clues for chemical dependency include unexpected behavioral changes, acute intoxication,
frequent job changes, unexplained financial problems, family history of substance abuse, frequent
problems with law enforcement agencies, having a partner with substance abuse, and medical
sequelae of drug abuse.
•
Condom use reduces transmission of HIV, Chlamydia, gonorrhea, Trichomonas, herpes virus, and
human papillomavirus.
•
It is important to ask about domestic violence when patients present with symptoms or behaviors
that may be associated with abuse.
•
When an abusive situation is identified, address immediate safety needs.
