Sea Base High Adventure Medical Form Page 5
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6PHYSICIAN’S MEDICAL EVALUATION
PHYSICIAN PLEASE NOTE
B. Care for injuries or illness:
A. Sea Base is a waterfront program where participants:
•
•
may take 6-12 hours or longer for direct assessment and
are on or in the water for extended periods of time
•
evacuation
are in high humidity with heat indexes reaching 110 degrees
•
•
may be delayed by thunderstorms or other natural problems
experience temperature ranges from 50-90 degrees F
1.
PHYSICAL EXAMINATION:
Height: _______________
Blood Pressure: _______________
Weight: _______________
Maximum Weight: _______________ (from chart)
Any individual exceeding the maximum weight of 300 lbs. will not be permitted to participate
Normal
Abnormal
Normal
Abnormal
Explain any abnormalities below:
Eyes:
Range of Mobility:
___________________________________
Ears:
Knees (both):
___________________________________
Nose:
Ankles (both):
___________________________________
Throat:
Spine:
___________________________________
Lungs:
___________________________________
Heart:
Other:
Yes
No
___________________________________
Abdomen:
Contacts:
___________________________________
Genitalia:
Dentures:
___________________________________
Skin:
Braces:
___________________________________
Emotional
Inguinal Hernia:
___________________________________
Adjustment:
2.
ALLERGIES:
(Any history of, list all problems: to what agent; type of reaction; treatment)__________________________________
______________________________________________________________________________________________________________
3.
IMMUNIZATION HISTORY:
(REQUIRED)
Tetanus immunization must have been received within 10 years prior to arrival at Sea Base: Date of Last Inoculation: ________________
Measles History: Inoculation:
Disease:
Unknown:
4.
RECOMMENDATIONS AND/OR RESTRICTIONS:
A. I certify that I have, today, reviewed the health history, examined this person, and find him/her physically fit to participate in the Sea Base
experience as outlined on this form, including:
Camping/Hiking: __Yes __No
Snorkeling: __ Yes __ No
SCUBA diving __ Yes __ No
Other Activities: __ Yes __ No
B. Restrictions (if none, so state)___________________________________________________________________________________
___________________________________________________________________________________________________________
5.
PHYSICIAN’S SIGNATURE:
Physician licensed to practice medicine (MD, DO). An examination conducted by a certified
physician’s assistant or a nurse practitioner will be recognized. (Please include the name and phone number of sponsoring physician)
Signature: _____________________________________________
To Heath Care Provider: Do not certify individuals whom:
⇒ Weigh in excess of 300 pounds
Address: ______________________________________________
⇒ Have significant heart disease, asthma, or hypertension
City, State, Zip: ________________________________________
⇒ Have incompletely controlled psychiatric disorders
Office Phone: (_______)_______________________
⇒ Are subject to anaphylaxis
⇒ Does not meet age requirements
Date: ______________________________________
THE SEA BASE HEALTH SUPERVISOR RESERVES THE RIGHT TO DENY THE PARTICIPATION OF ANY INDIVIDUAL
ON THE BASIS OF A PHYSICAL EXAMINATION AND/OR THEIR MEDICAL HISTORY. SEA BASE MEDICAL STAFF
WILL CHECK ALL MEDICAL EVALUATION FORMS BEFORE A PARTICIPANT BEGINS A TRIP. AREAS OF CONCERN
INCLUDE, BUT ARE NOT LIMITED TO: HEART DISEASE, HIGH BLOOD PRESSURE, SEIZURE DISORDER, SICLE CELL
ANEMIA, AND HEMOPHELIA, ASTHMA, DIABETES, AND EXCESSIVE WEIGHT.
-SEA BASE USE ONLY: DO NOT WRITE IN THIS BOX-
REVIEWED BY: _______________________________________ DATE: ___________________ RECHECK: _____ YES _____ NO
REASON: ___________________________________ RECHECK BY: ________________________________ DATE: ___________
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