UVM OUTING CLUB

MEDICAL HISTORY FORM

Name:_________________________________ E-Mail:__________________________

Home Address: ___________________________ Home Phone #___________________

Local Address: ____________________________ Local Phone #: _________________

Emergency Contact #1 : _________________________Phone # : ___________________

Emergency Contact #2 : _________________________ Phone # : __________________

Physician’s Name: ___________________________ Phone # : ____________________

Insurance Company:__________________________ __ Policy # : __________________

Height: _______ Weight: __________ Birth date: _________ M or F : ______________

Belly Button: Innie or Outie: __________ Date of Last Physical Exam: ______________

Please answer the following questions:

1. Please list any major illnesses or injuries you have had in the past five years including: operations, fractures, illnesses and or psychiatric/psychological conditions:

2. Please list all major injuries or illnesses which you are currently receiving treatment / medication for and explain in detail how we can accommodate you.

3. Please list any medications you are currently taking and for what reason. (Includes Birth Control)

PLEASE TURN OVER

4. Please list any allergies that you have, including: medications, food, plants, and insects. Please explain in detail the reaction you have and the last time you had a reaction.

5. Please list any other conditions which may affect your performance in the wilderness environment (i.e. diabetes, heart condition, epilepsy, dietary restrictions, eating disorders, food allergies)

6. Are you allergic to BEE STINGS? If so, how do you react? If you experience anaphylactic shock, you must see a physician and carry an anaphylaxis kit with you throughout the trip.

7. Are you experienced in the course element (hiking, rock climbing, skiing, etc.) that you have chosen? Please describe past involvement.

8. What do you do to maintain your physical fitness?

9. Have you ever experienced frostbite? Where on your body? When did this happen? Has it affected your circulation since then?

MEDICAL TREATMENT WAIVER

I hereby authorize UVM Outing Club Leaders, staff members, or other appropriate UVM personnel to administer or obtain on my behalf first aid, emergency medical care or admission to an accredited hospital when such care is necessary for the treatment of injuries sustained while participating in a UVM Outing Club Trip. I hereby give consent to the administration of emergency medical treatment in the event that I am unable, subsequent to injury, to give such consent as necessary.

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Name (Printed) Birth date

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Signature Date

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Signature of Parent or Guardian (if under 18) Date