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Courses
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Custom Adventures
College Semester Program
Career
About Us
Blog
Stay With Us
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Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Which course or program are you participating in?
*
Course Start Date
*
Date
Time
Course End Date
*
Date
Time
If you have, or have had, any of the following symptoms or conditions please check each box that applies. If none, type N/A in the box below.
Dizziness, loss of consciousness, recurrent headaches, or fainting
Eye, ear, nose, throat or sinus symptoms
Impairment of sight, hearing, or speech
Chronic cough, coughing up of blood, close contact with tuberculosis, bronchitis
Chest pain, shortness of breath, palpitation, swelling of ankles, heart murmur
Low or high blood pressure
Leg cramps, varicose veins, or varicose ulcer
Troublesome skin conditions, sensitive skin (sun exposure, allergies) rashes
Loss of teeth (indicate number of false teeth), use of dentures, bridge, braces
Albumin, sugar or blood in urine, kidney stones, or other urinary difficulties
Chronic pain in shoulders, arms, legs
Muscles, joint or back pain, bursitis, sciatica, swelling with injury
Knee injury or knee trouble
Benign or malignant growth or tumor
Frequent abdominal cramps, severe menstrual cramps, frequent diarrhea
Reaction to extremes of temperature, frostbite, impaired circulation
Claustrophobia, agoraphobia, acrophobia (confined places, open places, heights)
Motion sickness
Frequent infection of throat tonsils, sinuses, ears
History of diabetes, thyroid trouble, bleeding problems
Allergies to stings, bites, food, other
Allergies to codeine, antibiotics, penicillin, Benadryl, aspirin, Tylenol, Advil, etc.
Continued use of alcohol, drugs, or medicines
Do you smoke? If so, how much?
Do you use alcohol? If so, how much?
Special dietary restrictions, vegetarian, macrobiotic, etc.
If you checked any of the above boxes, please elaborate. If none please type N/A.
*
Have you had any of the following conditions or illnesses. Please check all that apply. If none, type N/A in the box below.
AIDS
Appendicitis
Arthritis
Asthma
Chickenpox
Colitis
Cystitis
Diabetes
Epilepsy/Convulsions
Gall Bladder
Hay Fever
Heart Disease
Hepatitis
Jaundice
Malaria
Measles/Mumps
Mono
Pleurisy
Pneumonia
Poliomyelitis
Rheumatic Fever
Tuberculosis
Typhoid Fever
Ulcer
Venereal Disease
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:
*
Have you had any of the following? Please check all that apply. If none, type N/A in the box below.
Blood transfusions
Dislocations
Hernias
Concussions
Fractures
Sprains/Strains
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 exercise
*
Daily
Regularly
Occasionally
Seldom
Never
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
*
Have any immediate family members had the following? Please select the conditions.
Allergies
High Blood Pressure
Anemia
Migranes
Bleeding Disorders
Nervous Conditions
Diabetes
Stroke
Epilepsy
Tuburculosis
Heart Disease
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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