Client Health and Medical Record (2023)

Participant Health and Medical Record
Who is filling out this form?*

ClientSomeone else on behalf of the client
Your Full Name (if filling this form out on a clients behalf)

First NameLast Name
I confirm that:

I have explicit consent from the client to complete and submit this form on their behalf, ORI have the authority to complete and submit this form on behalf of the client.
Your relationship to client (if filling out on a clients behalf)*
Client information

Tell us more about yourself (the client)
Full Name*

First NameLast Name
Preferred Pronouns*
Example: She/Her/Hers, He/Him/His, They/Them/Theirs
Date of birth*

MonthDayYear
Height*
Weight*
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BC Medical Number (or equivalent)*
Do you require 24 hour care?*

YesNo
Please be aware that CRIS staff and volunteers are not trained to provide personal care or behavioural interventions.

Clients requiring 24 hour care will need to be accompanied by a care aid (or equivalent support person) for the duration of the Trip, unless otherwise agreed with CRIS management.

Support personnel can attend free of charge, if you require more than one person, please contact the office to discuss your needs.
Who will be the primary contact for the client's account (who will be making bookings and communicating with CRIS)?*

The clientSomeone else
Name of primary contact*

First NameLast Name
Primary contact number*
Primary contact email address*
Emergency Contact Information

Who can we contact for you in an emergency?
Primary Emergency Contact*

First NameLast Name
Primary Emergency Contact Number*
Primary Emergency Email Address*
example@example.com
Secondary Emergency Contact

First NameLast Name
Secondary Emergency Contact Number
Secondary Emergency Contact Email Address
example@example.com
Health and medical information

Detailed information helps us to keep you safe
Do you have a Family Doctor?*

YesNo
Family Doctor Name*

First NameLast Name
Family Doctor Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please check all conditions, impairments or other challenges that apply*

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.Circulatory system: High or 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, urinary or bowel issues. etc.Musculoskeletal system / connective tissue: Osteoporosis, Arthritis, Scoliosis, neck/spine/back problems, etc.Endocrine system / 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) etc.Injury, or other consequences of external causes: Fractures or breaks, surgeries, brain injury, amputation etc.Skin conditions: Lupus, Psoriasis, Eczema or dermatitis etc.Other
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.
Circulatory system:
High or low blood pressure, irregular heartbeat, pace maker etc.
Digestive system:
High or low blood pressure, irregular heartbeat, pace maker etc.
Respiratory system:
Asthma, seasonal allergies, COPD etc.
Genitourinary system:
Symptoms affecting kidneys, ureters, bladder, and urethra, e.g incontinence, IBS, issues voiding , pregnancy, PMS etc.
Musculoskeletal system / connective tissue: Osteoporosis, Arthritis, Scoliosis, neck/spine/back problems, etc.
Osteoporosis, Arthritis, Scoliosis, neck/spine/back problems, etc.
Endocrine system / metabolic:
Symptoms affecting appendix, kidney, liver, thyroid, gallbladder etc.
Neoplasm (Cancers):
Leukemia, Breast Cancer, 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 disorders, Schizophrenia, Anxiety, Depression, Memory loss (short or long) etc.
Injury, or other consequences of external causes:
Fractures or breaks, surgeries, brain injury, amputation etc.
Skin conditions:
Psoriasis, Eczema, Dermatitis etc.
Other (Please Specify):
Please list any allergies you have, if you carry medication such as an EpiPen, please make a note of it.*
Needs and adaptations assessment

Detailed information helps us to adapt our activities for you
Please tell us about your level of mobility (select all that apply)*

Fully Ambulatory (Has normal use of all limbs)Partially Ambulatory (with assistive device or support)Non Ambulatory (Self propelled manual wheelchair)Non Ambulatory (Self driven powered wheelchair)Non Ambulatory (Wheelchair propelled by a care aid or equivalent)Limited range of motion (upper body)Limited range of motion (lower body)Monoplegia (Paralysis localized to one area of the body, such as a limb)Hemiplegia (Paralysis affecting both limbs on one side of the body)Paraplegia (Paralysis typically affecting the body below the waist)Quadriplegia (Paralysis typically affecting the body below the neck, may or may not include the arms).Other type of paralysis not specifiedCompromised muscle toneIssues with balance or coordinationLimited grip strengthLimited staminaProne to collapsing or faintingDifficulties with fine motor skillsHypermobilityOther
Please describe the assistive device or support you typically require to be ambulatory:
CRIS can adapt activities in a variety of ways. Telling us what works best for you helps us to determine how we can support you.
Please describe your preferred method of wheelchair transfer:
CRIS staff and volunteers are trained in wheelchair transfers, but we like to know your preferences. Please specify if you prefer a self transfer, assisted manual transfer or a lift transfer. Describe how you prefer transfers to happen, paying attention to details unique to you and your needs.
PHYSICAL NEEDS:*
Please describe any physical challenges you face. If you have management and adaptation suggestions or requests, please make note of them here.
COMMUNICATION NEEDS: *
Please describe your average communication abilities, type/level of communication, and any barriers you face (Deaf/HoH, sight impairment, physical impairment impacting communication). Please note any language barriers (Sign Language, ESL, AAC). Describe your preferred methods of communication.
INTELLECTUAL/EMOTIONAL/BEHAVIOURAL NEEDS:*
Please note any challenges around emotional regulation, information processing, developmental delay, tolerance of stress and stimulation, triggers, inappropriate/aggressive behaviours, regulation/management tools and strategies.
Please list all medical devices/supports you may require during a Trip with CRIS:
Such as pacemakers, catheters, feeding tubes, communications devices (Hearing Aid, AAC devices), crutches, canes, wheelchairs, blood sugar monitors, respirators etc.
Medications
Are you currently taking any medication?*

YesNo
Will you need to bring your medications on Trips?*

YesNoNot Sure
Please list all medications that you are taking:
If you have medication allergies, please list them here:
Please list any concerns that have not been covered in the above answers that may affect your participation in activities.
Please sign here to confirm that the information you have provided in this form is accurate.

Clear
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Signature

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Should be Empty:

Participant Health and Medical Record

Client information

Emergency Contact Information

Health and medical information

Needs and adaptations assessment

Medications