Confidential Health Questionnaire

Confidential Health Questionnaire
Note: The information in this form is collected for medical purposes and gives permission to the School of Lost Borders guides on this trip to seek emergency medical diagnosis or treatment for you in the event that you are unconscious or unable to make your own decisions. We ask that you fill out one form for each program.
Today's Date

MonthDayYear
Date
Program Name
Program Start Date

MonthDayYear
Date
Program End Date

MonthDayYear
Date
Name of Participant

First NameLast Name
Age
Pronouns

SheHeTheyOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number

Area CodePhone Number
FOR EMERGENCY USE:
Your doctor's name
You doctor's Phone number
Medical Insurance Company
Group/Policy No.:
In case of emergency, notify:
Name of Emergency Contact
Relationship to Participant
Phone Number

Area CodePhone Number
1. Does your doctor know you are going to participate in this retreat?

YesNo
Does your emergency contact person know you will participate?

YesNo
Are you under the care of a physician?

YesNo
Have you described this program to your physician and discussed your plans to participate?

YesNo
Does your physician approve of you participating?

YesNo
Please describe any discussions you've had:
2. Are you seeing a therapist at present?

YesNo
Would your therapist disapprove of you entering this activity?

YesNo
If yes, please describe why:
3. Do you have any history of emotional or psychological problems?

YesNo
If yes, please describe:
Please list any medications you are taking for psychological problems:
4. Are there any reasons why you should not fast or live alone?

YesNo
If yes, please describe:
5. Do you wear a Medic-Alert Tag or any other marker of a medical problem?

YesNo
If yes, please describe:
6. Were you hospitalized in the last five years?

YesNo
If yes, please describe:
7. Do you have allergic or anaphylactic reactions to any insults, such as environmental substances, foods, drugs, insect bites or stings?

YesNo
If yes, please describe (including medications you carry for exposures):
8. Have you ever experienced a seizure of any kind?

YesNo
If yes, please describe:
9. Do you have heart disease of any kind?

YesNo
If yes, please describe:
10. Do you have a lung disease or any kind of breathing problem?

YesNo
If yes, please describe:
11. Do you have hemophilia or any other disorder that impairs blood-clotting?

YesNo
If yes, please describe:
12. Do you have any muscle, joint, or bone-related disabilities?

YesNo
If yes, please describe:
13. Do you have trouble with headaches?

YesNo
If yes, please describe:
14. Do you have any kidney disease?

YesNo
If yes, please describe:
15. Do you have hypoglycemia or diabetes?

YesNo
If yes, please describe:
16. Do you have any other chronic disease that, in any way, threatens your health?

YesNo
If yes, please describe:
17. If you walked on the level for a mile at an average pace, would you get out of breath, have pains in the chest, develop muscle fatigue or have pains in your legs?

YesNo
Describe your degree of fitness in your own words:
18. Are you taking any medication at the present time?

YesNo
If yes, specify each drug, the dose and the reason for taking:
19. Any dietary preferences or needs?

YesNo
If yes, please describe:
20. Have you been infected with COVID?

YesNo
If yes, when:
If yes, any persistent symptoms?

YesNo
Please describe:
Have you completed a full course of a COVID vaccine?

YesNo
If yes, please enter the date of your second vaccine:

MonthDayYear
Date
21. Have you had a tetanus shot in the last 10 years?

YesNo
If yes, please enter the date of your last shot?

MonthDayYear
Date
This information is accurate and complete. I agree to cooperate with the retreat facilitators to design a wilderness practice with full consideration of my health history and health concerns. I give my permission to the School of Lost Borders guides on this trip to seek emergency medical diagnosis or treatment for me in the event that I am unconscious or unable to make my own decisions. Our role in offering medical treatment will be limited to emergency first-aid and either transportation to the nearest medical facility, or contacting such a facility to arrange emergency transport.
Signature (if under 18 years old, must be parent or guardian's signature):*

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Confidential Health Questionnaire

FOR EMERGENCY USE: