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WALDEN Institute
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
).**
*
Indicates required field
Name of Caregiver
*
First
Last
Age
*
Caregiver Email
*
Phone Number
*
Name of Cancer Survivor Applicant with Whom You're Applying
*
First
Last
Relationship to Survivor
*
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?
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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?
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Yes
No
If yes, please describe
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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, problems, or new happenings with the following: Head/Eyes/Ears/Nose/Throat, Lymph Nodes, Heart, Pulse, Lungs, Abdomen, Skin, Genitourinary, Musculoskeletal, Pregnancy)
*
Submit