Wilderness Medical Society snowmass 2005 Page 11
Do you have any other significant medical problems which
have required the regular care of a doctor? Explain.
Have you been HOSPITALIZED in the last three years?
Do you have any ALLERGIES or have you had any bad
reactions to any drugs? Which ones and what side effects?
Are you currently taking any regular medications? If so,
Describe regular exercise habits and comparable outdoor
activities or recent trips.
Special warning and qualifying section for participants.
If you are an applicant for a high altitude climbing
expedition, please sign. "I have received and read Mountain
Travel-Sobek's letter on health problems at high altitude"
If you are age 65 or above, or the box is checked, your
physician must complete the following. Please provide
physician with trip itinerary, this form, attached note to
physician and letter of health problems at high altitude.
The physical form is simply as listed below.
The applicant ____________________________ Age____
has been examined and was found to be physically
qualified to participate in a trip of the type checked below:
I have discussed the above matters with my patient.
(Physician's signature block with address and telephone
The form asks for no particulars concerning the physical examination, even vital signs.
The entire matter of evaluating the physical qualification is left to the physician's
discretion, yet it is clear that the physician is being provided with guidance as to the level
of the trip's physical exertion requirements and remoteness.
would check the
appropriate box indicating
trip severity level