Medical Information Form

Sure Foot Medical Information Form
  1. Is the participant covered by a hospitalization/medical care policy?
  2. Personal Medical History: Does the participant have, or has he/she had any of the following conditions or symptoms? Mark every question either Yes or No.
  3. 1. High Blood Pressure
  4. 2. Heart Disease
  5. 3. Heart Murmur
  6. 4. Irregular Heart Beat
  7. 5. Tuberculosis
  8. 6. Hepatitis
  9. 7. Seizure Disorder
  10. 8. Bleeding Disorder
  11. 9. Blood Disorder
  12. 10. Asthma
  13. 11. Diabetes
  14. 12. Hypoglycemia
  15. 13. Anorexia
  16. 14. Bulimia
  17. 15. Cancer
  18. 16. Skin Problems
  19. 17. Circulation problems
  20. 18. Head injury
  21. 19. Head aches
  22. 20. Stomach Ulcers
  23. 21. Intestinal Problems
  24. 22. Heatstroke
  25. 23. Bladder Infection
  26. 24. Kidney Problems
  27. 25. Thyroid Problems
  28. 26. Allergy to Iodine
  29. 27. Hearing Impairment
  30. 28. Vision Impairment
  31. 29. Sleep Walking
  32. 30. Broken Bones
  33. 31. Neck Problem
  34. 32. Back Problem
  35. 33. Arm Problem
  36. 34. Shoulder Problem
  37. 35. Knee Problem
  38. 36. Ankle Problem
  39. 37. Leg Problem
  40. 38. Foot Problem
  41. 39. Currently Pregnant
  42. 40. Special Diet
  43. 41. Medical Equipment/Device
  44. 42. Surgery
  45. 43. Coldsores
  46. 44. Venereal Disease
  47. 45. Chronic/Frequent Illness
  48. 46. PMS or Menstrual Problems
  49. 47. Recurring Diarrhea/Constipation
  50. If you answered YES to any of the listed conditions/symptoms, please explain below. Include specific information about how long the condition lasted, dates of occurrence, and treatment. How do(es) this condition effect the participant's ability to hike, climb, lift, and carry a pack?
  51. Insects:
  52. Has the participant been stung by a bee, hornet, wasp, or yellow jacket before?
  53. Is the participant allergic to any insect bite or sting?
  54. Allergies: (Please include food, environment, and drug allergies)
  55. Medications: (Please list any medications the participant takes, including over-the-counter medications)
  56. Hospitalizations/Emergencies (Please List any hospital or emergency department visits in the last TWO YEARS)
  57. Having completed the above medical information form, I,
  58. hereby give Sure Foot Adventures Staff and Trip Leaders, and Emergency Personnel consent and permission to provide first aid and emergency medical treatment in the event the participant is injured during an adventure trip. I am aware that this medical information form will be kept with the Sure Foot Lead Guide, and that Sure Foot Adventures Staff and Trip Leaders will take precautions to keep this information confidential. I understand that many participants with a variety of medical/psychological difficulties can successfully complete adventure trips, but it is my responsibility to make the Sure Foot Adventures Staff aware of the participant's medical history. I acknowledge and understand that failure to truthfully and accurately disclose the required information in this form could result in serious harm to the participant and others. I understand the rigorous nature of the trip. I understand that professional medical attention could be several hours or several days away. I understand that I will be held responsible for the cost of an evacuation if the participant requires one. I understand the importance of this form and have answered all statements fully and truthfully. I understand that if I am at all uncertain about the participant's ability to participate in this trip it is my obligation to consult his/her physician.
  59. (By checking this box, I indicate that I agree with the above statement and that the medical information I provided above is accurate to the best of my knowledge.)
 

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