What We Do
TNT in the Press
What to Expect
Paying it Forward
Events & Initiatives
Mindfulness Classes at Cancer Treatment Centers
Schweitzer Mountain Night Skiing
Pictures & Videos
Caregivers may complete the following medical information about themselves to alert TNT staff of any previous medical history. It is not necessary to have a medical provider complete and send these forms on your behalf unless we have any questions or concerns.
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GWEN VICTORSON (
Name of Caregiver
Name of Cancer Survivor Applicant with Whom You're Applying
General Medical History
Please indicate whether you have any of the following?
Respiratory problems (e.g. asthma)
Neurological problems, including seizures/migraines
Auditory or visual problems
Significant physical weakness of extremities or history of limb amputation
History of hypertension
History of diabetes
History of bleeding/coagulation disorders, DVT or PE
History of acute mountain sickness, high altitude pulmonary/cerebral edema
History of cancer
If yes to any of these, please describe. For example, is the problem or issue well controlled on medications? Are there any potential triggers or complications? Here there ever been any hospitalizations related to the problem or issue?
Do you have a smoking history?
If yes, currently smoking? Number of years and packs per day? If quit, date and packs per day history.
Do you have any history of substance abuse?
If yes, please describe
Do you have any physical, cognitive, sensory or emotional conditions that could interfere with your ability to participate in this program?
If yes, please describe
Allergies & Medications
Do you have any allergies to medications, insects, bees, other?
If yes, please list allergies, describe reaction & whether you carry an epi-pen.
Current Medications (including non prescription). List: Dose, Frequency, Method of administration, & Reason for use
Most Recent Physical Exam
Please provide any information that you can for the following areas. If any is impaired or abnormal, please describe:
Height, Weight, Blood Pressure
Please describe any current issues or problems with the following: Head/Eyes/Ears/Nose/Throat, Lymph Nodes, Heart, Pulse, Lungs, Abdomen, Skin, Genitourinary, Musculoskeletal)