Caregiver Medical Form

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Caregiver Medical
History Form

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.

**THIS FORM MAY BE COMPLETED AND SUBMITTED ELECTRONICALLY USING THE ONLINE FORM BELOW (OUR SERVER USES A 128-BIT ENCRYPTED SSL CONNECTION) OR THIS PAGE MAY BE PRINTED AND SCANNED/EMAILED TO THE ATTENTION OF: GWEN VICTORSON (GWENVICTORSON@TRUENORTHTREKS.ORG).** 

Name of Caregiver *

First

Last

Age *

Caregiver Email *

Phone Number *

Name of Cancer Survivor Applicant with Whom You're Applying *

First

Last

General Medical History

Please indicate whether you have any of the following? *

Respiratory problems (e.g. asthma) Cardiac problems Gastrointestinal problems Genitourinary problems Neurological problems, including seizures/migraines Auditory or visual problems Joint 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?

Comments *

Do you have a smoking history? *

Yes No

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? *

Yes No

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? *

Yes No

If yes, please describe *

Allergies & Medications

Do you have any allergies to medications, insects, bees, other? *

Yes No

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) *

Submit

GET BACK ON TRACK!
TRUE NORTH TREKS is a national 501(c)3 nonprofit organization whose mission is to empower teens and young adults with cancer (and those who care for them) to live longer, healthier, happier and more meaningful lives as fully functioning human beings who actively create and contribute to the world that cancer took from them. We help the people we serve get connected to powerful and unique skills, tools, experiences, and resources that can enable them to reclaim their lives and get back on track.

FIND YOUR TRUE NORTH!
One of the primary ways that we fulfill our mission is by taking groups of teens, young adults, and caregivers from across the United States on free backpacking and canoeing treks in beautiful wilderness destinations where they can connect with nature (after going through something as unnatural as cancer treatment), connect with peers who have been through something similar, and connect with themselves through training and practice in mindfulness meditation and yoga. Our treks are typically offered as either a full week in the backcountry wilderness, or a long-weekend at a beautiful retreat facility with day excursions into nature. We also offer free health promotion support for all of our alumni, as well as free meditation and yoga classes at select cancer centers.

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True North Treks • 2219 Colfax Street • Evanston, Illinois • 60201

Caregiver Medical History Form

General Medical History

Allergies & Medications

Most Recent Physical Exam

Caregiver Medical
History Form