Stanford University Outdoor Education Participant Medical History Form (Short)
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1
2Outdoor Education
Instructor Notes
Participant Medical
History Form (Short)
Follow-up
Approval
Office Use Only
INSTRUCTIONS:
All the questions on this form are important. The answers are needed in order to assess your level of participation in the
program. Please answer every question in each section in detail. Incomplete forms will slow down the screening process, and may cause you to miss
out on your Stanford University program.
PART I
General Information
APPLICANT
Name
Daytime Phone # (
)
Gender
Male
Female Ht. ____ Wt. ____ Shoe Size
Evening Phone # (
)
Age ___ DOB ___/___/___ SUID#
FAX # (
)
Address_____________________________ Apt.
Email Address
City/State/Zip
Do you speak/understand English? Yes
No
PARENT/GUARDIAN
EMERGENCY CONTACT (other than parent/guardian)
Name
Name
Phone # (
)
Phone # (
)
Email Address
Email Address
PART II
Medical Information
A. Allergies
NONE
or…
(Including allergies to medicines, foods, insect bites/stings)
Allergy
Reaction
Medication Required ( if any)
B. Current Medications
NONE
or…
(Including psychiatric and over-the-counter)
Medication
Taken For: (Symptom/Condition)
Dosage
Date Started
Current Side Effects
Stanford University recommends that participants have a tetanus immunization (within 10 years)
PART III
Health Profile
(if yes to any of the following please list the # and explain on the back of this form)
#
Please √ one—If yes, describe below
Y
N
#
Please √ one—If yes, describe below
Y
N
1
Seizure within the past 1 year
6
Vegetarian or Vegan dietary needs (circle which one)
Hospitalization / Emergency Room / Urgent Care visit
Neck / Back / Shoulder / Knee / Ankle / Shoulder or other joint
2
7
within the past 1 year
problem
Asthma (If yes, please bring inhaler)
Currently Pregnant
3
8
4
Unexplained chest pain/pressure, shortness of breath,
9
Other cardiac conditions, e.g. heart murmur or other rhythm
rapid heartbeat, sweats, or exertional dizziness or
abnormality
faint spells
5
Gastrointestinal Problems
10
Other medical issues (please list):
PART VII
Participant Signature Required
I authorize Stanford University to release information regarding my participation in programs conducted by SOE to the above stated emergency contact(s) and fellow
participants as necessary. This information includes, but is limited to: Duration of event/trip, Medical Information, Legal Information. This consent is a waiver of my rights
under the Federal Educational Records Privacy Act. Permission is given for any emergency anesthesia, operation, hospitalization or other treatment that may become
necessary. You should know that over the years, many students with a variety of medical/psychological difficulties have successfully completed our programs, but we must
be aware of these conditions. Failure to disclose such information could result in serious harm to you and your fellow participants.
Applicant Signature
Date
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