Service Trip Medical Form
Use only if you don't have the current version. Use additional sheets if necessary.
This information will be used to acquaint the trip staff with any special medical conditions in advance. Also in the event of a serious injury or illness, medical history would be useful to the emergency medical personnel. These questions are NOT used to screen participants; however, the leader may contact you to discuss whether the trip will be safe and enjoyable for you with consideration of your particular medical condition.
Trip Number: ___________ Trip Name: __________________________
GENERAL INFORMATION:
Name:________________________________________(Mr., Mrs., Ms., Miss)
Address:_____________________________________
City: _______________________________State:_______Zip:________________
Home Phone(_____)________________Work Phone(_______)_______________
In the event of an accident, please notify:_______________________________
Address:_____________________________
City:_____________________________State:______Zip:________________
Home phone:(______)_______________Work phone(_____)_________________
If the above person is unavailable, please notify:________________________
Address:_____________________________
City:_____________________________State:______Zip:________________
Home phone:(______)_______________Work phone(_____)_________________
Medical Insurance:
You are strongly encouraged to have medical insurance and to bring your
insurance card or other documentation on the trip with you.
Insuring Company Name:______________________________________________
Policy Number:___________________________________
Contact Phone number, if applicable:______________________
Is your health suitable for working at altitudes above 8,000 feet and generally below 15,000 feet?____________ (*If other than good, please attach a sheet and explain)
Date of Birth___________ Rest Pulse_________ Blood Pressure:____/____
Height:_________ Weight:__________
Eyes:
Any problem with eyes or vision?__________
Glasses or contact perscription:__________ Do you wear contacts?________
We recommend bringing a spare set of lenses.
Allergies: Please include allergies to food, medication, insects, etc.
and be sure to note the types and severity of the reaction. Use additional sheet if
necessary.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Have you ever taken penicillin?__________ Reaction:________
Do you carry an anaphylaxis kit?________
Recent illness?______________
Accidents, operations, hospitalizations?______________
Recent exposure to infectious diseases?______________
Please describe any medications you are taking, and why you are taking them
(including birth control. diuretics, etc.):
______________________________________________________________________
______________________________________________________________________
Please note occurence of any of the following, give particulars for "yes" answers on a separate sheet:
______Bronchitis ________Asthma _______Pneumonia
______Pleurisy ________Epilepsy _______Tuberculosis
______Rheumatic Fever ________Diabetes _______Anemia
______Frostbite ________Thrombophlebitis _______Hearing Problems
______Exposure ________Back Problems _______Pulmonary edema
______Irregularities of heartbeat or rhythm
______Other heart or lung conditions
______Fear of heights or exposed places
Tetanus: The danger of tetanus in the backcountry is extreme. You MUST be innoculated against this fatal disease. Fill in the date of your most recent innoculation against tetanus:_____________
PHYSICAL EXAMINATION: A recent physical examination is recommended and may be required by your trip leader:
Date of most recent physical:
Physician's name:________________________________________
Date: Address:______________________________________________
____/____/____ Phone:(_______)______________________
Physician's signature:____________________________________
(if required by trip leader)
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PARENTAL AUTHORIZATION:
The following authorization is required of trip applicants under the age
of 21. You cannot be accepted without it.
I, parent/guardian of _________________________________________, understand
that she/he may not be under constant supervision and believe her/him to
be mature enough to handle this trip. I authorize the trip leaders to
give, or arrange for all necessary medical care in case of illness or injury.
Signature of parent/guardian:____________________________________________
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PLEASE SEND THIS COMPLETED QUESTIONAIRE DIRECTLY TO THE TRIP LEADER.
970412
From www.oocities.org/Yosemite/1270/medicalform.html