18
WILDERNESS MEDICAL ASSESSMENT
Exam Code ______
I. PERSONAL
Name: Last_____________________First________MI_____
Classification
Venture Participant
Address:______________________City________State____Zip______ A. Extreme
1. Extreme
Telephone # Home: (____)____________Work : (____)____________ B. High
2. High
Fax (____)______________E-mail address: _____________________ C.
Recreation 3.
Deconditioned
Age_____ Gender_____Occupation____________________________ D. Therapeutic 4. Risk Factors
Education (highest)_________________________________________
5. Manifestly Ill
II. HISTORICAL
1. Have you ever participated in:
A wilderness venture?
Yes_____ No_____
Desert activities?
Yes_____ No_____
Similar to this activity?
Yes_____ No_____
Jungle activities?
Yes_____ No_____
Mountaineering?
Yes_____ No_____
Canoeing?
Yes_____ No_____
Above 10,000 feet?
Yes_____ No_____
Kayaking?
Yes_____ No_____
Backpacking?
Yes_____ No_____
Marine activities?
Yes_____ No_____
Nordic skiing?
Yes_____ No_____
Other?
Yes_____ No_____
2. Medical problems with any of the above?_________________________________________________
__________________________________________________________________________________
3. Did you volunteer?
Yes_____ No_____
Were you recruited? Yes_____ No_____
4. Do you now or have you ever used:
Tobacco?
Yes_____ No_____
Alcohol?
Yes_____
No_____
Drugs? Yes_____
No_____
Steroids?
Yes_____
No_____
5. Have you ever had previous significant medical illness?
Yes_____ No_____
Please
describe:_____________________________________________________________________
6. Any problems with psychosocial or interpersonal relationships?
Yes_____ No_____
Please
describe:_____________________________________________________________________
7. Have you had previous surgical operations?
Yes_____ No_____
Please
describe:_____________________________________________________________________
8. Have you had immunizations for:
Tetanus? Yes_____
No_____
Yellow
fever?
Yes_____
No_____
Typhoid? Yes_____
No_____
Hepatitis
A? Yes_____
No_____
Flu?
Yes_____
No_____
Hepatitis
B? Yes_____
No_____
Pneumonia? Yes_____
No_____
Other?
Yes_____
No_____
9. Has anybody in your family had?
Diabetes?
Yes_____ No_____
Heart Disease?
Yes_____ No_____
High Blood Pressure?
Yes_____ No_____
Bleeding Disorder? Yes_____ No_____
10. Are you physically active?
Yes_____ No_____
Exercise program? Yes_____ No_____
Please
describe:_____________________________________________________________________
