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Staff
Medical
History Form
TNT staff must submit updated medical information every 2 years, or when any significant changes occur to your medical status (e.g., surgeries).
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
).**
Basic Info
*
Indicates required field
Name (as it appears on your driver's license)
*
First
Last
[object Object]
Date of Birth (MM/DD/YYYY)
*
Phone Number
*
Email
*
Preferred Departure Airport
*
Gender
*
Male
Female
T-Shirt Size
*
Small
Medium
Large
Extra Large
Emergency Contact
*
First
Last
Phone Number
*
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 history of using smokeless tobacco?
*
Yes
No
If yes, do you currently dip? Number of years and tins per day/week? If quit, date and tins per day/week history.
*
Do you have any history of substance abuse (e.g., alcohol, marijuana)?
*
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 food, 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)
*
Insurance Information
True North Treks requires that all staff have their own health insurance. It is your responsibility to make sure your insurance will cover you for the duration of the course. Staff will be responsible for obtaining any necessary pre-admission review. If you do not already belong to a regular health program, we suggest a short-term policy which you may buy from your local insurance agent.
Name of Insurance Company
*
Policy Number
*
Submit
