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

Date

Program Name

Program Start Date

Date

Program End Date

Date

Name of Participant

First NameLast Name

Age

Pronouns

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Phone Number

Area CodePhone Number

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?

Does your emergency contact person know you will participate?

Are you under the care of a physician?

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

Does your physician approve of you participating?

Please describe any discussions you've had:

2. Are you seeing a therapist at present?

Would your therapist disapprove of you entering this activity?

If yes, please describe why:

3. Do you have any history of emotional or psychological problems?

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?

If yes, please describe:

5. Do you wear a Medic-Alert Tag or any other marker of a medical problem?

If yes, please describe:

6. Were you hospitalized in the last five years?

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?

If yes, please describe (including medications you carry for exposures):

8. Have you ever experienced a seizure of any kind?

If yes, please describe:

9. Do you have heart disease of any kind?

If yes, please describe:

10. Do you have a lung disease or any kind of breathing problem?

If yes, please describe:

11. Do you have hemophilia or any other disorder that impairs blood-clotting?

If yes, please describe:

12. Do you have any muscle, joint, or bone-related disabilities?

If yes, please describe:

13. Do you have trouble with headaches?

If yes, please describe:

14. Do you have any kidney disease?

If yes, please describe:

15. Do you have hypoglycemia or diabetes?

If yes, please describe:

16. Do you have any other chronic disease that, in any way, threatens your health?

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?

Describe your degree of fitness in your own words:

18. Are you taking any medication at the present time?

If yes, specify each drug, the dose and the reason for taking:

19. Any dietary preferences or needs?

If yes, please describe:

20. Have you been infected with COVID?

If yes, when:

If yes, any persistent symptoms?

Please describe:

Have you completed a full course of a COVID vaccine?

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

Date

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

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

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):

Please use your mouse and cursor to sign inside the box.

Confidential Health Questionnaire

FOR EMERGENCY USE: