Form: Medical History & Physical Exam Record
Magna
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
1. Instructions
Complete every item in each section. If an item does not apply, please put N/A. Do not leave any
items or sections blank. Failure to supply all requested information could keep the student from
joining his/her crew on an off-campus trip.
Part III (the Physician Exam and Participation Approval, pp 5-7) must be completed and signed by a
physician, licensed nurse practitioner or physician’s assistant. This physician-provided component is
required upon initial enrollment. Thereafter updates of the Physical Exam are required at the
Beginning of grades 7 and 9. We require annual updates of Parts I and II of this form.
All information will remain confidential, and you should know that many students with a variety of
medical / psychological difficulties have successfully completed our expeditions, but we must be aware
of these conditions for the student’s benefit. Failure to disclose such information could result in
serious harm to the student and his/her peers and staff.
Parts I and II of This Form: General Information, Insurance Information, and Consent to Treat
Must Be Updated Annually
2. General Information
Student’s Full Legal Name ____________________________________________________________
Last Name, First Name, Middle Initial
Crew Leader Name ______________________________________ Grade: _________________
Street Address ______________________________________________________________________
City ___________________________________________ State __________ Zip Code ______________
Home Phone (______) ______-_________ Mom W / C Phone: (______) ______-_________
Dad W / C Phone (______) ______-_________ Other Phone: (______) ______-_________
Student Gender ____ Male ____ Female Birth Date _____/______/______ Age ________
Physician Name ___________________________________ Phone (______) ______-_________
Physician Address ___________________________________________________________________
Emergency Contact _________________________________ Relationship ____________________
Contact Address ____________________________________________________________________
Contact Number(s): H / W / C (______) ______-_________ H / W / C (______) ______-_____
Form: Medical History & Physical Exam Rec.doc
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Form: Medical History & Physical Exam Record
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
Student Name: _____________________________________
3. Insurance Information
Students should be covered by their own medical insurance.
Please provide the following information about your child’s medical insurance. If you do not have medical
insurance, see the Director of Operations for options.
Is the student covered by any hospitalization and medical policy? ___ Yes ___ No
Insurance Company Name ___________________________________________________________
Group and/or Policy Number __________________________________________________________
Insurance Co. Address _______________________________________________________________
Is pre-authorization required? _____ Yes _____ No Phone Number (_______) _______-_______
*A COPY OF YOUR INSURANCE CARD MUST ACCOMPANY THIS MEDICAL FORM*
4. Consent to Participate and to Treat
By signing below, I/we, the parent(s)/guardian(s) of the student named below do hereby give consent
for the student to participate in Entheos Academy Expeditionary Learning School fieldwork.
I/we understand that fieldwork can be physically and mentally demanding. On some trips, students
sleep in tents, under tarps or improvised shelters. Entheos provides suitable equipment and ample
meals, but may not be able to meet special dietary requirements.
Strenuous physical activity may include:
walking on uneven terrain
immersion in cold water
running
rock climbing
carrying packs up to 45 lb.
adjusting quickly to altitudes of up to 14,000 ft
bicycling on roads or trails
canoeing, kayaking or other water travel
By signing below, I/we, also give consent for any emergency anesthesia, operation, hospitalization or
other treatment which might become necessary. I understand that the experiences can be physically
and mentally strenuous, occurring in a remote wilderness area, far removed from health care facilities.
I certify that the information provided in all parts of this form is a complete and accurate statement of
the physical, medical and psychological factors which may affect this student’s participation in Entheos
fieldwork. I/we realize that failure to disclose such information could result in serious harm to my/our
child, other students and/or Entheos staff. I/we agree to indemnify and hold Entheos harmless if all
relevant information is not disclosed. I also agree to notify the Entheos office should there be any
change in the health status of the student named below.
____________________________________________________ _______/_______/_______
Parent/Guardian Signature Date
____________________________________________________
Parent/Guardian Name (PLEASE PRINT)
____________________________________________________ _______/_______/_______
Student Signature Date
Form: Medical History & Physical Exam Record
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
Student Name: _____________________________________
Part II of Form: Student History – Past and present medical information – Update Annually
Student Age:
Crew Leader:
A. Conditions & Symptoms – Does the student now have or ever had any of the following conditions?
Yes
No
1. High Blood Pressure
34. Motion Sickness
2. Heart Disease
35. Sleep Walking
3. Heart Murmur
36. Broken Bones
4 Irregular Heartbeat
37. Neck Problems
5. Tuberculosis
38. Back Problems
6. Recent exposure to active TB
39. Arm Problem
7 History of TB
40. Shoulder Problem
8. Positive TB Test
41. Knee Problem
9. Active Hepatitis
42. Ankle Problem
10. History of Hepatitis
43. Leg Problem
11. Seizure Disorder
44. Foot Problem
12. Seizure within past year
45. Currently Pregnant
13. Bleeding Disorder
46. Special Diet
14. Asthma
47. Learning Disability
15. Diabetes
48. Anemia, sickle cell trait or other blood
condition
16. Hypoglycemia
49. Uses medical equipment devices
17. Anorexia Nervosa
50. Communicable Disease
18. Bulimia
What
When
19. Cancer
20. Skin Problem
21. Frostbite
22. Circulation Problems
23. Active Bedwetting
24. Headaches
25. Stomach Ulcers
26. Intestinal Problems
27. Jaundice Problems
28. Heatstroke
29. Bladder Infection
30. Difficulty Urinating
31. Endocrine Problems
32. Hearing Impairment
51. Other
Do you currently or regularly have any of the following
symptoms?
52. Chest Pain/Pressure
53. Heart Palpitations
54. Unexplained Sweating
55. Frequent Shortness of Breath
56. Frequent Dizziness
57. Frequent Fainting
58. Heartburn
59. Muscle Cramps
60. Intolerance of Warm Temperatures
61. PMS or menstrual problems
62. Other current symptoms/conditions not noted above
33. Vision Impairment
If you have answered Yes to any of the above items, please explain below. Include the following:
- What specific symptoms are occurring?
- How long does symptom/condition last?
- How often does symptom/condition occur?
- How is symptom/condition cared for?
- When did symptom/condition last occur?
- What are the ways in which symptom/condition may restrict student’s activities in any way, including ability to
run lift and/or climb?
Item #
Responses to above questions
Yes
No
Form: Medical History & Physical Exam Record
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
Student Name: _____________________________________
B. Allergies
Allergy
Reaction
Medication Required
C. Medications: Is the student currently using any medication, including psychiatric and over-the-counter medications?
_____ Yes _____ No If yes, please list below.
Medication Name
Prescribed For
Dosage/Administration
Other Necessary Info.
Note: Medication can be administrated at school with completion of the Student Medication Request and Release
Agreement form which requires a physician’s signature. All medication, both OTC and prescription, remains in
the school office. Duplicate medication should be sent for fieldwork in non-breakable, waterproof containers
along with dosage instructions. Fieldwork prescription medication administration requires a Student Medication
Request and Release Agreement, again with a physician’s signature, even if the student does not take the
medication at school. (You can pick one up in the office)
D. Non-prescription Pain Medications: Entheos may choose to administer a non-prescription (over-the-counter)
pain or fever reducer medication at school to students who request them if the parent/guardian provides prior
consent here. Because we are a K-8 school, medication is available in pill, chewable or liquid forms. If you
would like Entheos to be able to do this, indicate so by circling “yes” for each medication type Entheos may
administer. Entheos will not contact you when these medications are administered.
Acetaminophen (Tylenol): Yes No Bismuth Subsalicylate(Pepto Bismol): Yes No Ibuprofen (Advil, Nuprin, Motrin): Yes
E. Immunizations
Immunization
Current immunization record must be
on file at school.
Requirement
Date of Last Tetanus Shot
Yes
F. Hospitalization / Emergencies
Please list any recent hospital or emergency department visits.
Date(s)
Reason
Length of Stay
G. Personal History
1. Height ___________ Weight __________
2. Has the student been in counseling with a psychiatrist, psychologist or other psychotherapist within the
past two years?
____ Yes ____ No
Is the student currently in treatment?
____ Yes ____ No
3. Please arrange for a release of information with the student’s counselor so we may contact him/her.
Have you done so?
____ Yes ____ No
4. Name of most recent counselor
_________________________________________________________________
Street Address ________________________________________________________________________________
City/State/Zip ________________________________________ Phone Number _____________________
No
Form: Medical History & Physical Exam Record
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
Student Name: _____________________________________
Part III of Form: Physician Examination & Participation Approval
1. To the Examining Physician
Entheos Academy Expeditionary Learning School is a kindergarten through 8th grade
public school that is affiliated with Outward Bound. As a regular part of the educational curriculum,
students participate in outdoor adventure activities (fieldwork). Fieldwork activities can range from a
short day hike to, for the older students, a more challenging river trip. Entheos provides suitable equipment
and ample meals, but may not be able to meet special dietary requirements. Field work can involve activities that are
physically and mentally demanding: The range of activities can include but are not limited to:
walking on uneven terrain
immersion in cold water
running
rock climbing
carrying packs up to 45 lb.
adjusting quickly to altitudes of up to 14,000 ft
bicycling on roads or trails
canoeing, kayaking or other water travel
Entheos is dedicated to ensuring thorough and comprehensive medical evaluation and screening for all
students. We appreciate your assistance in getting this form completed fully and submitted in a
timely manner. Please ensure you provide the following:
Descriptions of abnormalities found in the physical exam that an average person can
understand.
Answers to all questions on the form. If something does not apply to the named student, put
N/A.
AS the student’s primary health care provider, you know your patient best and you are in the best
position to evaluate and advise the student and Entheos on medical issues and readiness to participate in
Entheos fieldwork. Your input is vital. Please carefully review the student’s medical history. Summarize
and evaluate any currently active medical problems that can affect the student’s fieldwork experience.
2. Instructions
Please review Part II of this form, which the student’s parent/ guardian completed. Check it for accuracy and
completeness. Make any necessary corrections or additions.
Conduct a physical exam. Document the results by completing all the items in this section. If an item does not apply,
please put N/A. Please write legibly. Describe conditions, their impact and restrictions, if any, in a way that average
people can understand to ensure the student’s safety. Please pay particular attention to heart, lung, metabolic, and
musculoskeletal issues.
If you feel that any further tests, immunizations, or specialty referrals are required before the student participates in
Entheos fieldwork, please indicate this in the section provided.
If you have questions about this form or about the activities in which the student may participate,
please call the Director at Entheos (801-417-5444).
Thank you for helping our students to have safe fieldwork experiences!
Form: Medical History & Physical Exam Record
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
Student Name: _____________________________________
Student Age:
A.
Crew Leader:
History and Summary of Active Medical Problems and Restriction
Physician: Please describe active medical issues and their possible impact on fieldwork participation.
B. Physician Exam
Height ___________ Weight __________ Student is
underweight
overweight by __________ lbs.
Blood Pressure _________ If BP is over 150/90, repeat. 2 nd reading _________ Date ____/____/____
Resting Pulse Rate ___________ Pulse Irregularities?
Yes
No If yes, please describe and indicate
possible impact on fieldwork experiences. ___________________________________________________________
_____________________________________________________________________________________________
Exam Results
Physician: For each item, check whether it is normal (yes) or abnormal (no). For items marked abnormal, please
provide more information in the next table.
Are the following in normal condition?
Yes No
1. Eyes
14. Genitals
2. Ears
15. Back
3. Nose
16. CNS
4 Throat & Mouth
17. Lymph Nodes
5. Neck
18. Skin
6. Thyroid
19. Scars
7 Thorax & Lungs
20. Extremities
8. Heart
21. Shoulder
9. Heart Murmur (if present)
22. Knees
Functional
23. Ankles
11. Peripheral Vessels
24. Feet
12. Abdomen
25. Other (specify)
13. Hernia
If you have answered No to any of the above items, please explain below. Include the following:
- Nature of the abnormality?
- Treatment, if any, student undergoes in response
- What impact, if any, the abnormality may have on fieldwork participation
Item #
Answers to above questions
Yes
No
Form: Medical History & Physical Exam Record
Entheos Expeditionary Learning
2606 South 7200 West
Magna, UT 84044
801-250-5233
801-250-5240 (fax)
www.entheosacademy.org
Student Name: _____________________________________
C. Tests
Stress EKG Test: If the student, regardless of age, shows cardiovascular or pulmonary abnormalities on
examination, known cardiac limitations and/or or two or more of the coronary risk factors listed below, we
strongly recommend and may require a symptom-limited maximum-exercise stress test be administered prior to
fieldwork.
Coronary Risk Factors:
High blood pressure
Overweight or obesity
No regular aerobic exercise
Family history of heart disease
Current smoker
Diabetes
Do you feel a stress EKG is needed?
Yes
No
If yes, date administered? ______/______/______
Results of test were Normal Abnormal. Please forward a copy of the stress test report to Entheos, at the
address shown above. At Entheos if a student is given a stress EKG, a “normal” result is required to allow the
student to participate in Entheos fieldwork.
Additional Tests: If you feel that other diagnostic tests are indicated prior to the student participating in
fieldwork, please schedule and provide results including TB skin test, medication blood levels, if applicable.
Additional Test Results
Test
Date
Results: Normal/Abnormal (describe)
D. Immunizations
Immunization
Requirement
Are the student’s immunizations
current and up-to-date?
Yes
Date of Last Immunization
Needs:
Date Scheduled:
No
Please provide a copy of the child’s immunization record for the schools records.
E. Recommended Referral
Explain
_____________________________________________________________________________________
___________________________________________________________________________________________
Consulting opinion:
Enclosed
To be forwarded to Entheos, at the address shown above.
F. Summary
How long have you known the student? _____________________________
On the basis of your past knowledge, the student’s medical history and the present physical examination of
this student, do you feel this individual can participate in Entheos fieldwork?
Yes
No
Physician Name _______________________________________________________________________________
Address _____________________________________________________ Phone (________) _______-__________
Physician Signature ____________________________________________________ Date ___________________