Lewis and Clark College Outdoors

Health & Diet Questionnaire

The following information is for our trip leaders' file only and remains strictly confidential.
Student ID:
First Name: Last Name:
Height: Weight: Phone:
1 Do you have any allergies (to insects, food, medicines, pollen, etc.)?
Yes
No
If yes, please describe:
Allergen: Severity: Mild rash Severe rash Potential to disrupt breathing.
More details:
2 Please check Yes or No for the following conditions:
Yes No Chronic Illness Yes No Bone fractures, ligament or tendon injuries
Yes No Recent Surgeries (last 2 years) Yes No Back, shoulder, knee, ankle, any other joint
injuries (explain in comments section)
Yes No Asthma Yes No Diabetes, seizures, heart conditions, hypoglycemia,
any other conditions (elaborate in comments section)
Yes No High blood pressure
Yes No ADD, ADHD, Asperger's
Please describe below any of the conditions you checked 'Yes' to, and/or describe any other conditions not listed above. For injuries and/or recent surgery, please list the date of injury or operation and your present degree of recovery.
3 Are you currently taking any medication, including prescription medication? Yes No.

Please list any medications, including all prescription medications, you currently take and/or will take by the time of your trip.
Medication: Dosage: Frequency: Bringing on trip (yes/no):

Note: If you plan to bring medication, be sure to bring double the amount needed for the length of the trip. Give the extra amount to your trip leader so that if you lose your supply the leader will have the backup.
4 Year of your last tetanus immunization: .
If you cannot remember, was it within the last 5 years? Yes, No.
5 Are you currently, or do you have a history of treatment or counseling with a mental health professional? Yes, No.
If yes, please describe:
6 Do you have medical insurance through Lewis & Clark College? Yes No.
If no, please complete the following and/or fax a copy of both sides of your medical insurance card to (503) 768-7876.
Name of insurance company: City/State:
Group #: Plan #: Personal ID#:
Policy/Certificate ID #: Authorization Ph #:
7 Your Date Of Birth:
Month:
Day:
Year:
8 Food Preferences:
Yes No Are You a vegetarian? Yes No Do you eat beef?
Yes No Are you a vegan?* Yes No Do you eat chicken?
Yes No Do you eat dairy products? Yes No Do you eat pork?
Yes No Do you eat eggs? Yes No Do you eat fish?

*Note: There's an additional $10 / day charge to provide vegan meals or special diets such as gluten free meals (There is no charge for vegetarian meals).
9 Please list below any foods you particularly despise. We'll try to avoid these in planning the menu!
10 Swimming Ability. Please check one:
Non-swimmer Infrequent Recreational Strong swimmer Competitive
11 Do you exercise regularly? Yes No. If yes, please describe:
Activity: Frequency/Duration: Intensity:
Easy Moderate Competitive
Easy Moderate Competitive
Easy Moderate Competitive
12 Do you smoke? Yes No.
If yes, how much/how frequently?
Note: Answering 'yes' will not affect eligiability. Please remember though, College Outdoors trips are smoke-free.
13 Have you participated in any extended outdoor programs or courses? Yes No.
If yes, please specify the program and duration:
14 Primary contact in case of emergency (a parent, guardian or close relative):
Person's Name: City/State:
Home Phone: Business Phone: Cell Phone:


Secondary contact in case of emergency (a parent, guardian or close relative):
Person's Name: City/State:
Home Phone: Business Phone: Cell Phone:
15 Your family doctor:
Physician's Name: City/State:
Business Phone #: Alternative Phone #:
Please read carefully

I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that migt be found int he outdoors, it is my responsibility to bring the proper medication with me on this trip.

By checking this box I certify that all information given on this form is true to the best of my knowledge.
Thank You For Filling Out Our Health and Diet Questionnaire