Please complete this medical and health information form. Answering in the affirmative to any of the questions below will not automatically disqualify you from participating in the program.

Please be honest and forthcoming with your answers. Advanced medical care is NOT typically available during the program. JIRP will have medical personnel on hand, and all field staff will have Wilderness Advanced First Aid certification (minimum). The more complete medical information we have on hand, the more optimally we can assist in case of an emergency or medical issue.

Any divulged information will be kept private and will not be shared with any outside entity. By signing this form, you acknowledge that in the case of medical issue or need for treatment, this medical/health information may be shared with attending JIRP personnel and/or appropriate medical personnel.

Medical and Health History Form

Role on JIRP 2019 *
If you are acting in multiple roles, please choose your primary role.
(please specify feet/inches or centimeters)
(please specify pounds or kilograms)
Birthdate *
Birthdate
Primary Care Physician/Practitioner
Name *
Name
Phone *
Phone
Health History
Please explain any relevant answers in the space provided.
Do you have any lung problems, such as asthma, COPD, cystic fibrosis, or any ongoing respiratory issues?
Do you have any cardiac or heart conditions such as angina, CHF, coronary artery disease arrhythmia, or previous cardiac surgery?
Do you have either high or low blood pressure?
Do you have any untreated or ongoing dental issues?
Have you had fainting spells?
Do you have any gastrointestinal issues such as ulcers, GERD, Crohn's disease, ulcerative colitis, or other active condition(s)?
Have you had any form of hepatitis?
Do you have any musculoskeletal condition such as chronic back or joint pain, arthritis, or joint replacement?
Do you have any gynecological issues such as heavy bleeding, endometriosis, or other ongoing problems?
Do you think you may be pregnant?
Do you have any urinary issues such as frequent UTIs, frequent kidney stones, urinary retention, or other ongoing problems?
Have you ever had any form of cancer, including leukemia or lymphoma?
Do you have any ongoing skin issues such as eczema or psoriasis?
Do you have any ongoing mental health issues such as depression, anxiety, or psychosis?
Do you have any persistent or chronic infectious disease?
Do you have any blood disorder such as anemia, thrombocytopenia, bleeding disorder, or clotting disorder?
Do you have a history of allergy other than simple seasonal allergies ("hay fever")? This includes allergies to medications or food. If yes, please describe: the allergen, to which methods of contact you've been sensitive in the past (inhalation, skin contact, ingestion, etc.), the severity of your past reactions, the date of your last reaction, and what medical care (if any) was necessary (antihistamines, epinephrine, hospitalization, etc.).
Please list all surgeries you have had, not including simple skin procedures or dental procedures.
Please list all medications you take more than twice a month, including over the counter medicines. For prescription medications, please include dosage amount and frequency.
Vaccination History
JIRP requires all participants to have certain vaccinations. Please indicate below if you are current with the follow vaccinations and indicate the date when you received them:
Tetanus
Date given:
Pertussis (often given with tetanus)
Date given:
Date givent:
Date given:
JIRP reserves the right to exclude participation in the program due to lack of current vaccinations.
Additional Information
Signature
All information provided by me is accurate and correct. I agree to provide follow up information to JIRP in regards to any information disclosed here should it be requested. *