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Austin Peay State University Participant Medical Information & Agreement
Medical Information & Agreement
Name- (First/Last)
Write-In Answer
Birth Date- (Month/Day/Year)
Write-In Answer
Emergency Contact- (Name/Relation)
Write-In Answer
Emergency Contact Number-
Write-In Answer
Please click all that occur or have occured in your life-
High Blood Pressure
Irregular Heart Beat
History of Hepatitis
Bleeding Disorder
Seizure within the Last Year
Chronic Headaches
Respiratory Problems
Asthma
Diabetes
Ankle Problems
Hypoglycemia
Frostbite
Circulation Issues
Intestinal Problems
Bladder Infection
Kidney Problems
Hearing Impairment
Vision Impairment
Sleep Walking
Neck or Back Problems
Shoulder Problems
Knee Problems
Hand/Foot Problems
Currently/Recently Pregnant
Intolerance to Cold/Heat
Migraines
None of the Above
If yes was answered to any of the above items, please explain in the space provided-
(If none, type N/A)
Write-In Answer
Mental Health-
Please click all that occur or have occurred in your life-
Claustraphobia
Severe Anxiety
Post traumatic Stress Disorder
Eating Disorder
Psychosis
Bipolar Disorder
Drug/Alcohol Addiction
Sleep Disorder
Autism Spectrum Disorder
Phobias
Schizophrenia
Dementia
History of Self Harm
None of the Above
If yes was answered to any of the above items, please explain in the space provided-
(If none, type N/A)
Write-In Answer
Allergies? (
including medicines, foods, bites/stings, etc.- when was your last allergic reaction and what happened?
)
Write-In Answer
Medications?
(List any and all medications you are currently using, including over the counter products.
Also identify name, dosage needed and how many times a day- only bring an amount adequate for the length of the trip in the original containers with dosages
)
Write-In Answer
Hospitalizations? (list all visits within the last two years, and what you were treated for)
Write-In Answer
Do you have any dietary needs/preferences?
Write-In Answer
Can you swim?
Yes
No
Do you feel that you are
physically
and
mentally
capable of participating in Govs Outdoors trips?
Write-In Answer
Required
I understand that outdoor activities can be vigorous and require some physical activity. I agree to engage in these activities and understand that they may be strenuous.
Required
You are responsible for any information that has been omitted or withheld from this form.
The information provided on this form is correct as far as I know.
Required
Authorization for Treatment:
In the event that I am unable to consent due to incapacitation for any reason, I hereby give permission to the medical personnel selected by APSU Staff to order x-rays, routine tests, treatment and necessary transportation for me/or my child. I hereby give permission to the physician selected by the APSU Staff to secure and administer treatment, including hospitalization for myself or my child as named above. The completed forms may be printed for off-campus trips.
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