Client Health and Medical Record (2023/2024)

Participant Health and Medical Record
Who is filling out this form?
Your Full Name (if filling this form out on a clients behalf)

First NameLast Name
I confirm that:
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
2 digit month, 2 digit day, 4 digit year
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?
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)?
Name of primary contact

First NameLast Name
Primary contact number
Format: (000) 000-0000.
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
Format: (000) 000-0000.
Primary Emergency Email Address
example@example.com
Secondary Emergency Contact

First NameLast Name
Secondary Emergency Contact Number
Format: (000) 000-0000.
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?
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

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)

Other
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?
Will you need to bring your medications on Trips?
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.
Photo & Video Consent: We love capturing special moments during our activities! From time to time, we may take photos or videos to preserve memories and share highlights. Please let us know your preferences by checking the boxes below. You may check one, both, or neither option. If no boxes are selected, we will assume you do not consent to photo/video use and will fully respect your privacy.
Parent/Guardian's Name

First NameLast Name
Parent/Guardian's Signature
Should be Empty:

Participant Health and Medical Record

Client information

Emergency Contact Information

Health and medical information

Needs and adaptations assessment

Medications