Environmental Learning Institute

Confidential Medical History Form for TORCH Educator Courses - Summer, 2007

Please email form to: Dr. David Silverberg silverberg@alum.mit.edu or fax to: 480-275-3318.

Participant’s Name:

Course Title:

Course Dates:

Because of the physical nature of some of the course activities it is important for the staff to be informed of all medical conditions of the potential program participant.  If you have had any of the following conditions or are currently experiencing them, circle the number and give details below.  For any circled conditions, please have your health care provider directly address the condition in their approval for your participation in the course.  All information presented in this form will remain confidential.

1. Dizzy spells, motion sickness, fainting, convulsions, persistent headaches?
2. Frequent infection of throat, tonsils, sinuses, ears?
3. Chronic cough, bronchitis, bloody sputum?
4. Shortness of breath or asthma?
5. Chest pains on exertion or deep breathing?
6. Palpitation of the heart, irregular heart beat, heart murmurs, or poor circulation?
7. Jaundice or hepatitis?
8. Frequent abdominal cramps? Severe menstrual cramps?
9. Hernia?
10. Bladder infection, kidney infection, gastrointestinal problems, urinary difficulties?
11. Chronic pain in neck, back shoulders, arms or legs?
12. Broken bones, joint dislocations, serious sprains, weakness of muscles?
13. Joint pain, swelling or stiffness without injury?
14. Any severe injury to head, chest, internal organs?
15. Have you ever been in the hospital overnight? What for?
    
16. ALLERGY to medicines, foods, materials, insect bites, bees, environmental allergies, hay fever etc.? If Yes, what type of reaction do you have to the offending agent?
17. Reaction to extremes of temperatures, heat stroke?
18. Alcohol or drug dependency?
19. Episodes of diabetes, thyroid trouble, bleeding problems?
20. Have you undergone any operations?
21. Do you smoke cigarettes? If yes, how many a day?
22. Current or recent pregnancy?
23. Special dietary restrictions?
24. CURRENTLY TAKING ANY MEDICATIONS? If so, what?
25. Psychiatric problems?
26. Other?

If you circled any of the above items, please list details below according to item number.  Be specific (include dates, names of meds, etc.). Use back of sheet if needed.

Participant Signature:

Date:

TO THE PARTICIPANT’S HEALTH CARE PROVIDER:

The applicant has applied to participate in a field course with the Environmental Learning Institute. 

The Ladakh, India TORCH courses involve backpack hiking, dayhiking with a 20 pound daypack, hiking on trails and off-trails, traveling in a jeep for several hours on sometimes curvy mountain roads. The elevation of base camp in Leh Ladakh is 12,000 feet and the passes we cross are as high as 18,500 feet.    Participants will sleep in tents and shared rooms in a simple lodge.

The British Columbia Rainforest TORCH course involve hiking in the forest and tundra, dayhiking with a 20 pound daypack, hiking on trails and off-trails, traveling in a van for several hours on sometimes curvy coastal and mountain roads,  traveling in a motorboat on a choppy water surface.  Participants will sleep in tents, in sleeping bags with sleeping pads on the ground. 

Based on the inherent nature of field work, we’d like to know if you feel the applicant is physically fit to participate in the course.

Please comment:

Health Care Provider’s Signature:

MD, CNP, PA (please circle)

Date:

Health Care Provider’s Printed Name:

Health Care Provider’s Phone Number: