medical exam (to be filled out by a physician, lnp, or pa) · 2019. 12. 15. · updated &...
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Updated & Revised 11/1/2017 Page 1
MedicalExam(tobefilledoutbyaPhysician,LNP,orPA)IMPORTANTNOTEREGARDINGTHEMEDICALEXAM:Applicantsmaywaituntiltheyreceivepreliminaryacceptanceintotheprogramtoobtainamedicalexam(acceptanceswillbeannouncedApril3).Forapplicantswhoareofferedapositionintheprogram,medicalexamsaredueonApril17th.Ifyouchoosetowaittogetamedicalexam,pleasebesuretostillscheduleitnow.ApplicantswillnotbefullyacceptedintotheprogramuntiltheNatureBridgemedicalformisreviewedandapprovedbyNatureBridgestaff;thosewhoaregivenpreliminaryacceptancebuthavenotsubmittedtheirNatureBridgemedicalexambyApril17thwillforfeittheirpositionintheprogram.
***Thisformmustbeused–alternateformswillnotbeaccepted.***
ThispageistobecompletedandsignedbyaPhysician,LicensedNursePractitioner,orPhysician’sAssistant.
Totheexaminingphysician:
Oursummerbackpackingprogramisstrenuous.Wehikeapproximately5-10miles(8-16km)dailyathighaltitudes(8,000ft./2,500m)with30-50pound(13-18kg.)packs.Ourparticipantscanbefarremovedfromhospital-basedmedicalsupportservicesandasmuchas48hoursfromdefinitivecare.
Yourcarefulexaminationisanimportantpartofourmedicalscreeningprocess.Bysigningthisformyouindicatethattheparticipantisingoodphysicalcondition,adequateforsuccessfullyparticipatinginourstrenuoussummerbackpackingtrips.
Pleasefilloutcompletely.
ExamDate____________________NOTE:Exammusttakeplacewithinoneyearofprogramstartdate.
Patient’sName_________________________________________________________________
Height_________(circleft./cm.)Weight_____(circlelbs./kg.)BloodPressure_______/_______Pulse____________
Circleifnormal,describeonlyifabnormal:
Eyes__________________________________________ Ears___________________________________________
Nose_________________________________________ Throat&Mouth_________________________________
Thyroid_______________________________________ Lymphnodes____________________________________
Neck_________________________________________ Back___________________________________________
Extremities____________________________________ Shoulders_______________________________________
Knees ________________________________________ Ankles__________________________________________
Feet _________________________________________ Skin____________________________________________
Heart _______________________________________ Other___________________________________________
SummaryofActiveMedicalProblemsandRestrictionsPleaselistbeloworcircle:None
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
To submit, email completed form to [email protected]
Updated & Revised 11/1/2017 Page 2
ConditionsandSymptomsDoesthepatienthaveorhavetheyhadanyofthefollowingconditionsorsymptoms?
Ifyouhaveanswered“yes”toanyoftheaboveitems,pleaseexplainbelow.Includethefollowing:
• Whatspecificsymptomsareoccurring
• Howlongsymptom/conditionlasts
• Dateoflastoccurrence • Howoftensymptom/conditionoccurs
• Howyoucareforsymptom/condition
• Howsymptom/conditionrestrictsapplicant’sactivityinanyway(includingapplicant’sabilitytohike)
NOTE:IfPatienthassevereasthmaorsevereallergies,pleaseprovideanasthmaoranaphylaxisemergencyactionplan.
ItemNo. DetailedDescription(includingrestrictions,ifany)
Physician'sSignatureRequiredHowlonghaveyouknowntheapplicant? _______________________________________________________________
NameofexaminingPhysician(pleaseprint): _____________________________________________________________
Address:______________________________________Telephone:________________Fax: _____________________
Physician’sSignature________________________________________Date__________________________________
1. Tuberculosis £Yes£No 11. KidneyInfection £Yes£No 21. Ankleproblem £Yes£No
2. ChronicCough £Yes£No 12. ThyroidProblems £Yes£No 22. Kneeproblem £Yes£No
3. Asthma £Yes£No 13. HearingImpairment £Yes£No 23. Brokenbones £Yes£No
4. Diabetes £Yes£No 14. VisionImpairment £Yes£No 24. Motionsickness £Yes£No
5. Hypoglycemia £Yes£No 15. CirculationProblems £Yes£No 25. Learningdisability £Yes£No
6. RecentexposuretoactiveTB
£Yes£No 16. RespirationIssues £Yes£No 26. MedicalEquipment/Devices
£Yes£No
7. PositiveTBTest £Yes£No 17. Headaches £Yes£No 27. Specialdiet £Yes£No
8. ActiveHepatitis £Yes£No 18. IntestinalProblems £Yes£No 28. Sleepwalking £Yes£No
9. SeizureDisorder £Yes£No 19. BladderInfection £Yes£No 29. Eatingdisorder £Yes£No
10. BleedingDisorder £Yes£No 20. SkinProblem £Yes£No 30. Other: