Medical Form

Program Name*

Trip Leader/Group Name*

Your Name*

First Last

Email*

Birthdate*

MM

DD

YYYY

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?

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.

Severe Anxiety or Depression*

Yes
No

Please elaborate.

High Blood Pressure*

Yes
No

Please elaborate.

Heart Disease*

Yes
No

Please elaborate.

Seizure Disorder*

Yes
No

Please elaborate.

Asthma*

Yes
No

Please elaborate.

Diabetes*

Yes
No

Please elaborate.

Chronic Headaches*

Yes
No

Please elaborate.

Shortness of Breath*

Yes
No

Please elaborate.

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.

Comments

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