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Wilderness Reflections Health Questionnaire

Wilderness Reflections Health Questionnaire- Wilderness Quests

These questions are designed to protect your health and safety. Please answer them completely and candidly, using the reverse side of the page as needed.
Name
First Last
Trip Date
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Height
Weight
Date of Birth
Medical Insurance Provider
Policy #
Name of Doctor
Doctor's Phone
Emergency Contact
Emergency Contact Phone
Do you wear a Medic-Alert tag?
- Yes
- No
If yes, for what?
Have you ever been told by a doctor that you have high blood pressure, heart murmur or heart disease?
- Yes
- No
Dates?
Have you ever experienced a seizure of any kind?
- Yes
- No
If yes, please explain
Do you experience anaphylactic shock from bee stings or other insect bites?
- Yes
- No
Are you allergic to any drugs (e.g., penicillin, sulfa), environmental substances, or foods ?
- Yes
- No
If yes, please specify any such allergies
Do you have hemophilia?
- Yes
- No
Have you ever had any lung disease?
- Yes
- No
Do you have any disabilities or problems with back, hips, knees or ankles?
- Yes
- No
If yes, please specify
Have you ever been treated, hospitalized or placed in residential care for a psychological or psychiatric difficulty.
- Yes
- No
Are you taking any medication prescribed by a physician at the present time?
- Yes
- No
Have you recently? If yes, please specify
If you walked on level ground for one mile at an average pace would you get out of breath, have pains in the chest or legs, or develop muscle fatigue?
- Yes
- No
Do you have hypoglycemia? Diabetes?
- Yes
- No
Are there any reasons why you should not fast or live alone in the wilderness?
- Yes
- No
If you are under the care of a doctor, would they approve of your participation in this activity? Ask them if you cannot answer this question confidently.
- Yes
- No
Any other medical information we should have? Serious illnesses etc.(use back of pg)
Signature
Date
Parent/Guardian's Signature
(if under 18, signature by parent or legal guardian grants consent to treatment)
Date

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