FIELD COURSEMEDICAL REPORT– CONFIDENTIAL
318 Structure Pre-Fall 2017
INSTRUCTIONS TO THE STUDENT: Please fill out the Part I – Health History before your appointment and submit it to your physician or health care provider at your medical screening exam. Note: Please be sure to let your physician know that you will be participating in a field course and you are required as part of the application process to have a medical screening. You can have your evaluation done at the Student Health Center. Please schedule your appointment ASAP either with the Student Health Center or your Physician. Deadline to have Medical Report to the Health Center is August 4, 2017.
Submit the completed Medical Report (Parts I, II and III) to the Student Health Center, CS 201in a sealed envelope.
INSTRUCTIONS TO THE PHYSICIAN: You are requested to evaluate the physical and mental health of a student planning to participate in a field course. Participants spenda number of days in remote outdoor locations in the Western U.S. The pressures of living and studying in this environment can be considerable. It is extremely important that participants be able to handle exposure to:
- Hazardous anddemanding conditions - including weather and terrain; conditions range from cold (20º - 40º F) to very hot (95º- 110º F) depending upon the location
- Climbing and hiking for long periods of time while carrying a heavy (20 to 30 lbs.) pack; daily hikes of 3-8 miles, with changes of elevation of 1000 feet or more, are typical
- High altitude exposures;
- Strenuous activity and physical exertion;
- Substantial changes indietand living conditions;
- Limited availability of immediate medical assistance;
- Exposure to wildlife; and
- In general, the demands of living in a very challenging physical environment.
Students camp in tents for the duration of the course, which offers few amenities, little comfort and little privacy. They need tact and sensitivity when dealing with other participants. They also need the emotional maturity to make good decisions and use good judgment while living and studying alone at times with their peers.
A student will be asked to leave for any physical or emotional condition that substantially impairs their participation in the course. Information regarding the student's current health is invaluable toGeologyfaculty and staff in anticipatingand responding to any potential health problems which may arise during the student's participation. Your insight will be very helpful.
It is essential that your assessment be based on a current (within the last 12 months) and thorough physical examination and knowledge of the student's medical and mental history.
Please give the completed Medical Report to the student upon completion of your exam. Thank you for your assistance.
MEDICAL REPORT
INSTRUCTIONS TO THE STUDENT:
Please complete the course information below and the health history questions in PART I below to the best of your ability, sign, and submit this form to the examining physician or health care provider, who will complete PART II and PART III. Parts I, II and III should then be submitted to the Student Health Center, CS 201in a sealed envelope marked “Confidential”.
LAST NAME______FIRSTNAME______
BIRTH DATE MM/DD/YY ______/______/______MALE FEMALE
WWU STUDENT NUMBERW______
FIELD COURSE NAME ______NUMBER______
QUARTER AND YEAR ______
PART I: HEALTH HISTORY (To be completed by student - check boxesand describe conditions that apply)
Your physician’s name______Phone ______
My general health is: Excellent Good Fair Poor
List any recent or continuing health problems: ______
List any physical or learning disabilities: ______
Are you currently under the care of a health care professional, including for mental health treatment? Yes No
Professional’s title andName: ______Phone/Fax: ______/______
Address: ______
For what condition(s):______
Are you currently seeing other health professionals as well? Yes No If so, use additional paper and include name, phone number, address and condition being treated.
Allergies:None
Medications (give details)______Sunlight
Peanuts or other foods (give details)______Insect stings or bites
Pollens (hay fever)
Specific plants or molds (give details) ______
Dust or smoke
Other (give details) ______
Medications:None
Vitamins – Please list______
Herbal – Please list______
Antidepressants – Name of medication______
Seizure medications – Name of medication______
Birth control pills – Name of medication ______
Inhalers – Name of medication ______
Insulin injections/pump
Other medications (give details) ______
Diet: Regular or Vegetarian/Vegan
Restricted (give details) ______
Habits:Tobacco Use - Former or Current - What kind______Amount per week______
Alcoholic beverages – Amount per week______
Coffee/Caffeinated beverages
Exercise – Forms______How often______
Devices:Contact lenses or Corrective lenses (eyeglasses) or Both
Hearing aid Right Left
Prosthetic joints or other devices (give details)
Other (give details) ______
Medicalhistory:
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Dizziness, nausea
Diabetes
Arthritis
Shortness of breath or asthma
High blood pressure
Knee, ankle, elbow or other jointproblems
Hospitalizations, injury or illness
Recent broken bones, sprains or dislocations
Bleeding disorders, hemophilia, anemia
Severe menstrual cramps
Claustrophobia or acrophobia
Chronic back, neck, arm or leg pains
Heart disorders, palpation murmurs, irregular beats
Continuing drug or alcohol abuse
Episodes of depression, emotional difficulties, anxiety, hysteria, nervousness
Physical challenges or handicaps
Difficulty adjusting to high altitudes
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Headaches
Epilepsy
Ulcer/colitis
Hepatitis/gall bladder disease
Bladder/kidney problems
Cancer/tumors
Thyroid problems
Recurrent or chronic infectious diseases
Tuberculosis (TB)
Syphilis
HIV/ AIDS
Surgery
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Vertigo, dehydration, heat tolerance
Give dates and details for checked items ______
______
______
Mental Health Treatment: Have you been treated by a physician, psychiatrist, psychoanalyst, psychologist, or therapist for ANY mental,emotional, or nervousdisorder within the past 5 years?* Yes* No
Give details ______
Current medications______
*If yes, your examining health care provider may need a report from your psychiatrist or therapist in order tocompletethisform.
Vaccine status:Tetanus Vaccine: Yes No When? ______
Western’sMeasles Immunity Report Form (contact Western’s Student Health Center before answering): A Report Form or Waiver Form is on file at Western’s Student Health Center Not sure of mystatus
EMERGENCY CONTACT INFORMATION:
Name:______Relationship:______Phone: ______
Name:______Relationship:______Phone: ______
EMERGENCY CONTACT: I authorize the release of information to the above listed emergency contacts in the event of an emergency.
STATEMENT: The answers I have given are correct and true to the best of my knowledge. I understand that failure to provide complete and accurate information may be grounds for non-participation in the field course. I further understand that failure to disclose health care problems may also lead to serious health consequences, including death while studying in the field.
______
Signature of StudentDate
RELEASE OF INFORMATION: I authorize the release of information in this report to the Geology Department at WWU,and its leaders and coordinators of the field course, includingany information regarding TB, HIV/ AIDS, sexually transmitted diseases, mental illness, substance abuse and/or any other health information that may be protected under HIPAA or similar laws regarding confidentiality.
______
Signature of StudentDate
PART II. SCREENING EXAMINATION:
(To be performed by the physician or health care provider)
A standard medical screening should be documented in the clinic’s official medical record only, and together with any medical reportssubmitted from outside consultants, is subject to standard policies governing release of confidential health data. Annual health exams forfemale patients of reproductive age may require a separate appointment. Note: evaluations from the WWU Student Health Clinic are acceptable.
NOTE: It is our position not to accept reports completed by parent-physicians.
PART III. MEDICAL ASSESSMENT:
(To be completed by the physician or health care provider after reviewing PART I and completing PART II)
Are the statements given by the student in Part I of the Medical Report correct to your knowledge? Yes NoHeight: ______Weight: ______
General state of health: Excellent GoodFair Poor
Comment on affect and habitus: ______
1. Is the student significantly underweight or overweight? YesNo
2. Is the student allergic to any form of medication? YesNoSpecify if “yes”______
3. Has the student any physical disability that might cause hardship through strenuous physical exercise, carrying heavy loads, or change of diet? Yes No
4. Does the student have a history of asthma or any acute or chronic illness?YesNo
5. Does the student have any active infectious or contagious diseases?YesNo
6. Is the student currently under treatment for any physicalor emotional health, or chemical dependency diagnosis?
Yes* No
*If so, please elaborate in the space provided on the following page or submit a physician’s letter that further explains the patient’s condition.
7. Is there any history of mental health diagnosis such as mood disorders, anxiety disorder, eating disorder or other thatmay impact thestudent’s adjustment to living and studying in a remote, outdoor environment? Yes* No
*If so, please elaborate in the space provided on the following page or submit aphysician’s letter that further explains the patient’scondition.
8. Are further medical consultations recommended before this student participates ona field course? Yes* No
Women’s Health Mental Health
Sports Medicine Nutrition
Eye exam, expanded** Hearing exam, expanded**
Dental exam** Allergy & Infectious diseases**
**Not available at the Western’sStudent Health Center.
Student Health Center to confirm status of Western’s Measles Immunity Requirement
Other medical consultations (please specify) ______
Note: Consultations require separate appointments, except for consulting the Student Health Center to check on measles immunity status.
9. To your knowledge, are there any predisposing medical, surgical, or emotionalfactors which may under stress or duress during the program present a need forimmediate therapy or treatment while living and studying in a remote, outdoor environment for a long period of time? Yes No
If the answer to any of questions 1 thru 9 above is “Yes”, please elaborate in the space provided below, or further explain on a separate, signed note that is printed on physician’s office or clinic letterhead. Please be sure to refer to the question by its number:
CONCLUDING ASSESSMENT: Based upon the information provided to me by the student under PART I – Health History, and pursuant to an assessment of the student’s health condition as determined in Part II – Screening Examination, and Part III – Medical Assessment, I find:
There are NO medical or psychiatric contraindications to participation, and the student is cleared for the field course.
The student is CONDITIONALLY cleared for the field course. These conditional clearances is contingent upon the student arranging for the following, with concurrence from theGeology Department that such arrangement are suitable for the type of field course in which the student plans to participate:
Further medical consultation as recommended in item 8 above (see page 5).Consultation with WWU disAbility Resources for Students counselor about disability noted in item 3 above.
Other arrangements must include:
There ARE MEDICAL contraindications to participation and in my judgment the student is NOT cleared for the field course.
There ARE PSYCHIATRIC contraindications to participation and in my judgment the student is NOT cleared for the field course.
PHYSICIAN NAME (please print) / PHYSICIAN SIGNATURE / DATEADDRESS / ZIP CODE / TELEPHONE NUMBER
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