Adventure Trip Participant Form

Participant History & Medical History

First and Last Name
UT Affiliation
UT EID
Academic Major or Occupation 
E-Mail Address
Preferred Phone Number
Address (including City, State, Zip Code)
Date of Birth (00/00/0000)
Age:
Height:
Weight:

Are you covered by a personal medical insurance plan?

This includes if you are covered by your parent's medical insurance plan or if you have purchased medical insurance from University Health Services. If you are not covered by any medical insurance plan you must check NO. If you checked YES, a copy of your insurance card must be uploaded.

Please upload a copy or photo of your insurance card (if you have one):
Required
MEDICAL HISTORY
A. Have you ever experienced any of the following:
B. Do you have any allergies to the following:
If any of the above 2 questions are checked- please explain: (If none, write N/A)
C. Are you currently taking any medications?
If yes- for what conditions? (if none, mark N/A)
Please list medication, dosage side effects/restrictions: (if none, mark N/A)
D. Are you allergic to any medications?
If yes, please list: (If none, write N/A)
E. Do you plan to take any prescription medications on the trip?
(For extended trips lasting 4 days or longer- please bring an extra quantity of medication on the trip to be left in the medical kit)
F. Diet Considerations:
Foods I will not or cannot eat include: (If none, write none)
G. DO YOU HAVE A HISTORY OF: 
1. Respiratory Problems or asthma?
2. If you have asthma is it well controlled with an inhaler? (if so, bring an inhaler with you)
3. What triggers an astma attack? (If none, write N/A)
4. Have you ever been hospitalized?
5. Have you ever had any gastrointestinal disturbances?
6. Do you have diabetes?
7. Have you ever had bleeding, deep vein thrombosis, or blood disorders?
8. Have you ever had neurological problems or epilepsy?
9. Have you ever had seizures?
10. Have you ever had dizziness or fainting episodes?
11. Have you ever had migraines?
12. Have you ever had disorders of the urinary or reproductive tract?
13. Have you ever had any diseases or conditions we should know about?
14. Have you ever had/do you have hypertension?
15. Do you have cardiac problems or unexpected chest pains?
16. Have you ever had a heat stroke or heat related illness?
Do you see a medical or physical specialist of any kind?
I. Do you currently have or had a history within the past 3 years of:
A. Knee, hip, or ankle injuries (including sprains) and/ or surgery?
Is there full range of motion (ROM)?
Do you have full strength back?
What is the most rigorous activity you've participated in since the injury/surgery? (If this doesn't apply to you, type N/A)
B. Have you had shoulder, arm or back injuries (including sprains) and/or surgery?
Is there full range of motion?
Do you have full strength back?
What is the most rigorous activity you've participated in since the injury or surgery? (If not applicable to you, type N/A)
C. Any other joint problems?
D. Head injury?
E. Have you ever had loss of consciousness?
Please use this space to explain any special health needs not addressed in the above questions (if there is nothing, write "N/A")
J. Please Rate yourself in the following areas: [check the description which best fits your skill level or experience]
1. Swimming ability:
2. Fitness Level:
3. Camping/backpacking experience:
4. Canoeing/rafting experience:
5. Length of longest outdoor/camping trip:
6. Rock Climbing Experience:
7. Have you ever been to the trip location before?