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Medical Form
Medical Form
2016-12-23T19:52:37-08:00
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Program Name
*
Custom Trips and Private Guiding
Hiking and Backpacking
John Muir Trail Hike
Take A Load Off Your Back
Whitney Via Cottonwood
Whitney Mountaineers Route
Whitney East Face
Whitney East Buttress
Whitney in Winter
Williamson/Tyndall Climb
Mt. Russell via the Fishhook Arête
A Day on the Rocks
Rock I: Introduction to Rock Climbing
Rock II: Introduction to Multi-pitch Climbing
Rock III: Introduction to Anchoring
Rock IV: Introduction to Leading
Rock V: Self-rescue Training
Multi-pitch Weekend
Sport Climbing weekend
Classic Alpine Rock Climbs
Classic Alpine Ice Climbs
Mini Mountain Camp
Extended Mountain Camp
Courses and Skill Building
Snow Skills
Parents and Kids Trips
Backcountry Skills
Hut Based Trips
Sierra Wilderness Ski Tours
Downhill in the Backcountry
Winter Mountaineering
Introduction to Ice Climbing
Wilderness First Responder Training
Wilderness First Responder Recertification
Level I Avalanche Course
Level II Avalanche Course
OTHER
Trip Leader/Group Name
*
Your Name
*
First
Last
Birthdate
*
Month
Day
Year
Email
*
Phone
*
Height
*
Weight
*
Gender
*
Female
Male
Please describe in detail your previous relevant outdoor activities.
*
Rock/ice climbing, skiing, backcountry skiing, mountaineering, wilderness hiking, gym climbing etc…
Fitness Regimen
*
Please describe your physical conditioning program, if any.
My fitness is...
*
Please describe your physical condition.
Special Diet Needs/Requests
*
If this is a program where SMC is providing food, do you have any special dietary needs or requests? Are you Vegan/Dairy Free/Gluten Free/Egg Free/Vacuum Eater? If none of the above, just put N/A.
EMERGENCY CONTACT INFORMATION
Emergency Contact
*
Emergency Contact - Relationship to you
*
Emergency Contact Phone
*
Emergency Contact Secondary Phone
Emergency Contact Email
MEDICAL PROVIDER & INSURANCE
Please provide details about your medical provider.
Physician's Name
*
Physician's Phone
*
Health Insurance Provider
Health Insurance Policy Number
MEDICAL HISTORY
Do you now have, or have you had within the past two years, any of the following conditions?
If “yes” to any of the conditions below, please explain in the space provided.
Altitude Illness
*
Yes
No
Please elaborate.
*
Broken Bones
*
Yes
No
Please elaborate.
*
Severe Sprains
*
Yes
No
Please elaborate.
*
Shoulder or Neck Problem
*
Yes
No
Please elaborate.
*
Back Problem
*
Yes
No
Please elaborate.
*
Foot or Ankle Problem
*
Yes
No
Please elaborate.
*
Leg or Knee Problem
*
Yes
No
Please elaborate.
*
Arm or Hand Problem
*
Yes
No
Please elaborate.
Intestinal Problem
*
Yes
No
Please elaborate.
Urinary Tract Problem
*
Yes
No
Please elaborate.
Heat or Cold Intolerance
*
Yes
No
Please elaborate.
Uncorrected Vision or Hearing Impairment
*
Yes
No
Please elaborate.
*
Diagnosed Mental Illness
*
Yes
No
Please elaborate.
*
Will you be able to wear a mask when required?
*
Yes
No (please call the office at 760-873-8526)
SMC requires face masks be worn any time during a trip when social distancing is impossible.
Severe Anxiety or Depression
*
Yes
No
Please elaborate.
*
Will you be able to wear a mask when required?
*
Yes
No (please call the office at 760-873-8526)
SMC requires face masks be worn any time during a trip when social distancing is impossible.
High Blood Pressure
*
Yes
No
Please elaborate.
*
Heart Disease
*
Yes
No
Please elaborate.
*
Seizure Disorder
*
Yes
No
Please elaborate.
*
Asthma
*
Yes
No
Please elaborate.
*
Will you be able to wear a mask when required?
*
Yes
No (please call the office at 760-873-8526)
SMC requires face masks be worn any time during a trip when social distancing is impossible.
Asthma Medication
*
I have medicine prescribed for asthma and will be bringing it with me
I currently have no medicine prescribed for asthma
Diabetes
*
Yes
No
Please elaborate.
*
Chronic Headaches
*
Yes
No
Please elaborate.
Shortness of Breath
*
Yes
No
Please elaborate.
*
Will you be able to wear a mask when required?
*
Yes
No (please call the office at 760-873-8526)
SMC requires face masks be worn any time during a trip when social distancing is impossible.
Chest Pain
*
Yes
No
Please elaborate.
*
Hospitalization in Past Year
*
Yes
No
Please elaborate.
*
Are you currently pregnant?
*
Yes
No
What is your due date?
*
Are you currently taking any prescription medications?
*
Yes
No
Please list medications and dosage, one per line. Please include medical marijuana use.
*
Are you allergic or sensitive to any foods, insect bites, medications, or other?
*
Yes
No
Please explain what you are allergic/sensitive to, the reaction, and treatment required.
*
Do you have any other condition that could affect your performance during physical activity, including your ability to run, lift, climb, or ski?
*
Yes
No
Please describe limiting conditions.
*
Please review & confirm your medical history
*
We find that sometimes people fail to assess their health and abilities fully or honestly and end up suffering on an outdoor trip at elevation.
Everything looks good!
In the past two weeks have you had any of the following symptoms?
*
None of the above
Dry cough
Shortness of breath or difficulty breathing
Fever
Chills
Sore throat
New loss of smell or taste
Your Covid-19 Exposure Risk
*
Yes
No
Do you work, play, or live in a Covid-19 high-risk environment?
You clicked "yes" or "other." Please elaborate below.
*
Have you had a recent Covid-19 test?
*
Yes
No
Exposure Transparency Consent
*
I agree to be forthcoming with any possible Covid-19 symptoms
Do you agree to inform SMC office staff and/or guides if you begin experiencing any of the above symptoms, at any time before, during or after your scheduled trip?
Guideline Consent
*
I agree to follow SMC's Covid-19 guidelines
Do you agree to follow the guidelines given to you by SMC and your guide, and that failure to comply with these guidelines may result in the early termination of your trip?
Vital Check Consent
*
I consent to temperature and/or pulse ox readings
SMC may take temperature and oxygen saturation levels at the beginning of the trip and at periodic times throughout the duration of your trip. These checks are not invasive and you can perform them on yourself if desired.
Followup Consent
*
I agree to the followup policy.
After the trip SMC may follow up by phone or email to ask if you are showing any Covid-19 symptoms.
Signature (or guardian signature)
*
Please sign to confirm your cooperation with our Covid-19 risk reduction plans (as indicated by your consents above).
Phone
This field is for validation purposes and should be left unchanged.