Staff Medical Form

Contact Information

First Name *

Last Name *

Address 1

Address 2

City

State/Province

Zip

Phone *

Email *

Additional Information

Birth Date *

// (mm/dd/yyyy)

Gender *

Preferred Personal Pronoun

T-Shirt Size *

X-Small
Small
Medium
Large
X-Large

Preferred Departure Airport *

Emergency Contact Information

First Name *

Last Name *

Phone *

Email *

General Medical Information

Please indicate whether you have any of the following: *

No known medical conditions
None of the issues listed below
Respiratory problems (e.g. asthma)
Cardiac problems
Gastrointestinal problems
Neurological problems (including seizures/migraines)
Auditory or visual problems
Joint problems
Significant weakness of extremities or history of limb amputation
History of hypertension
History of diabetes
History of bleeding/coagulation disorders, DVT or PE
History of acute mountain sickness, high altitude pulmonary/cerebral edema
History of cancer

Please explain any of the medical issues or conditions indicated above. *

Do you have a history of smoking? *

Yes
No

If yes, please describe use (number of packs per day and duration) including current use or quit date (if applicable).

Do you have a history of using other forms of tobacco (e.g. chewing)? *

Yes
No

If yes, please describe use (quantity per day and duration) including current use or quit date (if applicable).

Do you have a history of alcohol or substance abuse? *

Yes
No

If yes, please describe use (substance and duration) including current use or recovery date (if applicable).

Do you have any physical, cognitive, sensory, or emotional conditions that might interfere with your ability to participate in this program? *

Yes
No

If yes, please describe the condition and how you believe it might interfere with your participation.

Are you pregnant? *

Yes
No

Allergies and Medications

Do you have any food, medication, or insect (e.g. bee sting), or other allergies? *

Yes
No

If yes, please explain the allergy including reaction and epi-pen use.

Please list all current medications (prescription and non-prescription) including dose, frequency, administration method, and reason for use. *

Most Recent Physical Exam

Please provide any information you are able to report below, including a description of any impairments or abnormalities.

Height, weight, and blood pressure *

Please describe any current head, eye, ear, nose, throat, lymph node, heart or heart rate, lung, abdominal, skin, genitourinary, or musculoskeletal issues. *

Health Insurance Information

True North Treks requires that all staff have their own health insurance. It is your responsibility to make sure your insurance will cover you for the duration of the course. Staff will be responsible for obtaining any necessary pre-admission review. If you do not already belong to a regular health program, we suggest a short-term policy which you may buy from your local insurance agent.

Insurance Company

Policy Number

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Date Medical Form Submitted

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Staff Medical Form

Contact Information

Additional Information

Emergency Contact Information

General Medical Information

Allergies and Medications

Most Recent Physical Exam

Health Insurance Information