MedicalHistory

ProgramEntry-Confidential-

COMPLETETHISFORMANDRETURNTO:

PNWAdult&TeenChallengeRegionalOfficeIntakeCoordinator6902SELakeRoad–Suite300Milwaukie,OR97267Phone:(503)765-5252Fax:(971)254-9892Intake@teenchallengepnw.com

Pleasereadcarefullythefollowinginstructions.

1. ThefirsttwopagesconcernthePhysiciansReport.ThefirstpageidentifiestheteststhatmustbeconductedbyaPhysicianandthelabresultssentintoPacificNorthwestAdult&TeenChallengeRegionalOffice6902SELakeRdSuite300,Milwaukie,OR97267orfaxedto(971)254-9892.

2. ThephysicalExamistoruleoutcontagiousdiseasesorsignificantmentalorphysicalimpairment–

similartoasportsphysical–(useDoctor’sforms);3. Thespecificteststobeconductedarelistedbelow:

• Tuberculosistest:PPDorchestx-rayorothertestsasrecommendedbydoctor.• Genitalexam–ifindicatedforsexualtransmitteddiseases;• HIVtest;• HepatitisPanel–Complete(includesA,BandCscreeninglabtest)

4. IftheapplicantistakingaparticularmedicationwhileintheTeenChallengeprogram,theattending

physicianshouldhavesufficientinformationtoverifyitandstatetheprescribedmedicationanddosageonpage2.Thisisamustoryoumaynotbeallowedtotakethemedication.

5. Non-prescriptionItems–Studentsarepermittedtobringnon-prescriptionitemsintotheprogramorreceivethemfromoutsidetheprogram(aspirin,etc.),if,andonlyif,theyareenclosedinthemanufacturersoriginalpackageandthewrappingsealisunbroken–NOEXCEPTIONS.

6. TheMedicalHistoryistobefilledoutbytheapplicantandreturnedtotheaddressbelow.

Theapplicant’ssignaturebelowauthorizesthetestslistedabovetobecompletedandtheresultsandinformationsenttoPacificNorthwestAdult&TeenChallengeRegionalOffice6902SELakeRdSuite300,Milwaukie,OR97267.

Applicant’sName(print): Applicant’sSignature: Date:

PACIFICNORTHWESTADULT&TEENCHALLENGE

PHYSICIANSREPORT

Physician’sReport(continued)

Uponexamination,thepatient’sgeneralphysicalhealthwasfoundtobe:

Good Average Poor

Thepatientisexperiencingamedicalconditionthatrestrictstheirparticipationinphysicallabor.

Yes No

Ifyes,pleaseexplain:

Physician’sAuthorizationofMedication

Listanymedicationprescribedforthepatientbyyouoranotherphysician.Pleaseindicateifanyoftheseprescriptionsarehabitformingtoyourknowledge.

Medication PrescribedFor HabitForming

Yes No

Yes No

Yes No

Yes No

Yes No

Physician’sName(print):

PhoneNumber: FaxNumber:

Address:

Physician’sSignature: Date:

Pleasereturnthisandalltestresultsandinformationto:PacificNorthwestAdult&TeenChallengeRegionalOffice–6902SELakeRd,Suite300,PortlandOR97267Fax(971)254-9892.

PACIFICNORTHWESTADULT&TEENCHALLENGEMEDICALREPORT

ApplicantsName:

Sex: Male Female DateofBirth: Height: Weight:

Married: Yes No Howlong? Nationality:

BloodType:

Currentphysician: Phone:

PacificNorthwestAdult&TeenChallengeiscommittedtohelpingstudentsbecomephysically,mentallyandspirituallywhole.Wearenot,however,amedicalprogram.Wewillendeavortoassistyouinsecuringwhatevermedicalhelpwecanwhileyouareintheprogram.Ifyoubecomeillorneedmedicalattentiononceyouareintheprogramwewillassistinconnectingyouwithamedicalfacility.Youareresponsibleforanyfeesthataccrueinconnectionwithyourvisittooftreatmentfromanymedicalfacility.Wedonotfinanciallyassiststudentsinmeetingtheirmedicalbills.

ExplaininthespacebelowanyprovisionsyouhavetocovermedicalexpenseswhileenrolledinTeenChallenge?

HealthInsurance: Yes No InsuranceCompany:

PolicyNumber: Doesyourpolicyrecognizerecoveryservices? Yes No

Doyoucollectdisabilitypayments? Yes No

EmergencyContactInformation

Name: Phone:

Address: City: State: Zip:

Relationshiptoapplicant:

PersonalMedicalHistory

Areyoucurrentlybeingtreatedbyaphysicianforanillness,injuryormedicalsymptom? Yes No

Ifsopleaseprovidethenameofthephysician:

Address: Phone:

Describeanyillness,injuryorsymptoms:

Areyoucurrentlyreceivingtherapyforanyofthecircumstancesdescribedabove? Yes No

IfYes,pleaseexplain.

Areyouexperiencingorhaveyouexperiencedaninjuryorillnessthataffectsyourabilitytoparticipatein?

ManualWorkExperience

ExercisePrograms

RecreationalActivities

Yes No

Yes No

Yes No

Ifyestoanyoftheabove,pleaseexplain.

Pleaselistanyfoodallergies

Areyouallergictobeestings? Yes No Doyouneedmedicationifstung? Yes No

Areyouallergictoanymedications? Yes No

Pleaseidentifyallmedicationsyouareallergictointhespacebelow.

Checkifyouhave:

HayFever Diabetes Asthma Seizures Epilepsy

Convulsions Blackouts Arthritis Dizziness ChronicFatigue

ChronicBackaches SinusTrouble Migraines BlurredVision DoubleVision

LossofSight LossofHearing EarInfections HighBloodPressure LowBloodPressure

Gonorrhea Syphilis Herpes Aids Chlamydia

Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No

Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequencybelow:

Checkifyouhave: HeartTrouble ChronicCough Hemorrhoids Ulcer’s Jaundice

HeartBurn AcidReflex BlackStool KidneyStones Hepatitis

Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No

Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequencybelow:

Areyouexperiencing: PoorAppetite Nausea Vomiting VomitingBlood

FrequentIndigestion FrequentDiarrhea FrequentConstipation

IntestinalParasites PersistentWeightGain PersistentWeightLoss

CoughingupBlood BloodinUrine FrequentUrination

Bladderinfections ProblemsUrinating SevereItching

ProblemsSleeping Depression Anxiety

Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No

Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequency:

Haveyouhad: Measles ChickenPox ScarletFever WhoopingCough

Mumps SmallPox TyphoidFever Diphtheria

Tuberculosis Pneumonia Cancer Anemia

NervousBreakdown HeadInjury

Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No

Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequency:

Ifyouhavehadaheadinjurywhereyoulostconsciousnessorwereadmittedtoahospitalforevaluation,pleaseexplainthenatureofyourinjuryandifexperienceanddifficultiesasaresultoftheinjuryinthespacebelow.(memoryloss,lackofconcentration,headaches,visionproblemsetc.)

Describeanyillnessordevelopmentalconditionthatyouexperiencedasachild?

Describeanyseriousinjuriesorbrokenbones:

Identifyanymajorsurgeriesyouhaveexperiencedstartingwiththemostrecent:

Doyouhaveanyspecialdietrestrictionsorrequirements? Yes NoPleaseexplain:

Dateoflasteyeexam: Results: Excellent Good Fair Poor

Areyourequiredtowearprescriptionglasses? Yes No Doyoupresentlyownapair? Yes No

Dateofyourlastdentalexam: Conditionofyourteeth: Excellent Good Fair Poor

Pleasedescribeanyproblemsthatyouareexperiencingwithyourteeth.

Howmanycupsofcaffeinateddrinks(coffee,tea,pop,energydrinks)doyouhaveperday? Cups

Howmanypacksofcigarettestoyousmokeperday? Doyouusechewingtobacco? Yes No

Haveyoueverreceivedmentalhealthtreatmentnotrelatedtodrugoralcoholuse? Yes No

NameofClinic Date:

ReasonforMentalHealthTreatment:

NameofClinic: Date:

ReasonforMentalHealthTreatment:

NameofClinic: Date:

ReasonforMentalHealthTreatment:

NameofClinic: Date:

ReasonforMentalHealthTreatment:

WouldyoubewillingtoauthorizereleaseofinformationfromtheaboveclinicstoTeenChallenge? Yes No

ForWomenOnly

Agewhenyoufirstexperiencedaperiod: Daysbetween: Lengthofperiod:

Doyouhavenormalmenstrualcycles? Yes NoIf no, pleaseexplaininthespacebelow.

Doyouexperiencea Heavy Medium Lightflow?

Doyouexperienceanybleedingbetweenperiods? Yes NoPleaseexplaininthespacebelow.

Whenwasyourlastpelvicexam? Date: Werethereanyadversefindings? Yes No

Pleaseexplain:

Doyouthinkyouarepregnantatthistime? Yes No

NumberoffulltermPregnancies:

Haveyouexperiencedanymiscarriages? Yes No Haveyouhadanyabortions? Yes No

Pleaseexplainanycomplications.

Haveyouexperiencedmenopause? Yes No

Pleaseexplainanycomplicationsbelow.

Haveyouexperiencedaneatingdisordersuchasanorexiaorbulimia? Yes No

Pleasedescribeindetailincludinganytreatmentyouhavereceivedforthisinthespacebelow.

SubstanceAbuseandTreatmentHistory

Indicatebelowthealcohol,drugandmedicalprogramsyouhaveattended.

DateAdmittedandDischarged Program/Facility ReasonforLeaving

Pleaseexplaintypesoftreatmentandcounselingreceived.

Pleaseusethechartbelowtodescribeyouruseofalcoholanddrugs.

Whenansweringthequestionof“HowOftenTaken”,useOforOnce,STforSeveralTimes,RforRegularlyandCforcontinuoususage.

ALLDRUGTYPESUSED:(includestreetdrugs,

alcohol,illegalprescriptions,overthecounter&otherdrugs.)

CURRENTLY

USING

PRESCRIBED

BYAPHYSICIAN

AGEWHENFIRSTUSED

AGEWHENLASTUSED

HOWOFTENTAKEN

CHECKUSUALMETHODOF

ADMINISTRATIONYES NO YES NO Oral Smoke Snort IM IV

Alcohol

Amphetamines/speed(UppersBenzedrine,Dexedrine,etc.)

Anti-depressants

Barbiturates/downers

Chew–Tobacco

Cocaine/crank

Codeine

Darvon

Diladud

Hallucinogens(LSD,Acid,Mescaline,etc.)

Heroin

Inhalants(Glue,Paint,Gasoline,etc.)

Marijuana/hashish

Meth

Methadone–non-legal

Opiates(Percodan,Opium,Morphine)

PCP(AngelDust,etc.)

Ritalin

Tobacco–smoking

Tranquilizers

Valium,Librium

Other(specify):

Theundersignedfullyacknowledgesthattheinformationprovidedhereinisaccurateandtruetothebestofhisorherknowledge.Anyfalseorincompleteinformationmaycauseandresultindisqualificationfrom

admittanceordismissalfromtheprogram.

Applicant Date

IF THIS APPLICATIONFORMHASBEENCOMPLETEDORFILLEDOUTBYANYONE, OTHERTHANSTUDENTAPPLICANT, PLEASEPROVIDEFOLLOWING:

Nameofindividualfillingouttheform Date

RelationshiptoApplicant