Client Health and Medical Record 2021

#BREAKINGDOWNBARRIERS TO OUTDOOR SPORT AND RECREATION SINCE 2001
Community Recreational Initiatives Society
email: admin@adaptiveadventures.ca

835 Bay Ave. Kelowna, BC, V1Y 7K2
Participant Health and Medical Questionnaire
The following information is used to provide CRIS personnel with an assessment of each participant's medical history for safety purposes. This information will remain confidential. Please be as detailed as possible. It is your responsibility to update CRIS personnel of changes in your health/meds/etc. that occur after filling out your Health and Medical Record.

PLEASE BE AS DETAILED AS POSSIBLE TO HELP US BEST ASSIST YOU.
Today's date *

Month Day Year
Date
Last name *
First name *
Date of Birth *

Day Month Year
Date
Gender

Male Female Other Choose not to identify
Height *
Weight *
Address: (street, city, prov, post code) *
Primary Contact

Participant contact information
Phone: Cell *
Phone: Home
Phone: Other
Email *
example@example.com
Relationship (if primary contact is not the participant)
Emergency Contact
1. Name *
Relationship *
Home Phone
Cell Phone *
Other
2. Name
Relationship
Home
Cell
Other
BC MEDICAL NUMBER: (in case of emergency) *
Allergies: food, medicines, insects, plants, chemicals) Note ANY and ALL. Please explain signs, symptoms & treatment. *
Health and medical conditions
Please check all that apply. Please specify any and all condition(s) or challenges you have and describe in the section that follows. (*This list is not comprehensive) *

Sensory system: Deaf, partially deaf, blind, partially blind, visual neglect, depth perception, colour blindness, etc. Nervous System: Cerebral palsy, paraplegia, quadriplegia, hemiparesis, seizures, neuropathy, spasticity, etc. Respiratory System: High our low blood pressure, irregular heartbeat, pace maker, etc. Digestive system: Ulcer, irritable bowel syndrome, trouble swallowing, etc. Respiratory system: Asthma, seasonal allergies, COPD etc. Genitourinary system: Severe pms or menstrual problems, currently pregnant/breast feeding, urinary/bowel issues Musculoskeletal system / connective tissue: Osteoporosis, arthritis, scoliosis, neck/spine/back problems, etc. Endocrine system, nutrition/metabolic: Diabetes, problems with appendix, kidney, liver, thyroid, gallbladder etc. Neoplasm (cancers): Leukemia, skin cancer, etc. Blood & blood forming organs & immune system: hemophilia, anemia, HIV, etc. Congenital & Chromosomal: Huntington's, down's syndrome, FASD, autism, SMA, etc. Mental illness: eating disorder, schizophrenia, anxiety, depression, memory loss (short or long term) Injury or other consequences of external causes: fractures or breaks, surgeries, brain injury, amputation Skin conditions: Lupus, psoriasis, eczema, dermatitis, etc. Other: Please note below
Please provide details regarding the boxes checked above
Specific condition(s) or injury *
Date of injury or diagnosis (if acquired)
Current status
Treatment / management plan and techniques *
Any other relevant details *
Are you taking any medications? *

Yes No
Please list (name, amount, frequency & times of intake)
Mobility
Are you independently ambulatory *

Yes No
Ambulatory with an assistive device

Yes No
Please provide a list of any assistive devices or personal care devices you will be using when participating (manual or power wheelchair, crutches, walker, cane, braces/orthotics, catheter, respirator, hearing aid, communication devices, etc.)
Do you transfer independently

Yes No
Do you transfer with assistance from another person or device

Yes No
Please explain your ideal transfer
Communication abilities: uses sign language, apraxia, aphasia (receptive/expressive), uses communication device, does not communicate, etc. *
Please list any medical or physical concerns that have not been covered in the above answers that may affect your participation in activities (ie. pain, range of motion limitations, etc.)
**THE INFORMATION PROVIDED ON THIS FORM IS ACCURATE TO THE BEST OF MY KNOWLEDGE AS OF***
Day *
Month *
Year *
Legal Name (print clearly) *
Signature *

Clear
Name of parent or legal guardian (if under the age of 18 or unable to sign)
Signature of parent or legal guardian

Clear
Adaptive Adventures - Making the outdoors accessible for people of all abilities
Should be Empty:

#BREAKINGDOWNBARRIERS TO OUTDOOR SPORT AND RECREATION SINCE 2001

Community Recreational Initiatives Society

Participant Health and Medical Questionnaire

Primary Contact

Emergency Contact

Health and medical conditions

Please provide details regarding the boxes checked above

Mobility