Confidential Medical History – Summit Adventure

Name *

First

Last

Which course or program are you participating in? *

Course Start Date *

Date

Time

Course End Date *

Date

Time

If you checked any of the above boxes, please elaborate. If none please type N/A. *

If you checked any of the above boxes, please elaborate and state the year(s) of occurrence. If none, please type N/A. *

Describe any special physical or emotional limitations: *

Are you up to date on Tetanus immunization? *

Date of last Tetanus immunization or booster

Date of last physical exam: *

Please give the dates and details of each occurrence of any of the above, if applicable. If none, please type N/A. *

If you have ever been hospitalized state the date, illness, injury, or operation.

Select the words in the following four sentences that best describe you.

My general health condition is: *

Excellent
Good
Fair
Poor

My level of aerobic condition is: *

Excellent
Good
Fair
Poor

I can swim *

A mile
A short distance
Not at all
I'm afraid of water

Family Health History

Mother's date of birth, occupation, state of health *

Father's date of birth, occupation, state of health *

If immediate members are not living, give cause of death and age.

Dietary

We will provide meals for the entirety of the course, breakfast, lunch, dinner and snacks. Please let us know if you have any dietary restrictions or preferences (gluten free, dairy free, vegan etc.)

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