2021 Xplore Health & Diet Questionnaire

In the unlikely event of an accident or medical emergency, we need to have your medical information readily available. For this reason, it is critical to fill out the health and diet questionnaire thoroughly, indicating all current medications, past injuries, and any present conditions. This information is for the program’s files only and remains strictly confidential.

All fields marked with asterisk (*) are required.

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Look for it on your Admissions letter. If you can't find it, please enter "Don't Know."
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xxx-xxx-xxxx
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Do you have any allergies (to insects, food, medicines, pollen, etc.) or food intolerances?*
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Please check Yes or No to the following conditions: Chronic illness*
If you answered "yes", please describe in detail in the space provided below.
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Recent surgeries (in the last two years)*
If you answered "yes", please describe in detail in the space provided below.
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Asthma*
If you have been provided an inhaler, be sure to bring it, even if you don't anticipate using it.
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High blood pressure*
If you answered "yes", please describe in detail in the space provided below.
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ADD, ADHD, Asperger's, Depression, Bipolar, or other mental health issues*
If you answered "yes", please describe in detail in the space provided below.
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Bone fractures, ligament or tendon injuries*
If you answered "yes", please describe in detail in the space provided below.
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Back, shoulder, knee, ankle, any other joint injuries*
If you answered "yes", please describe in detail in the space provided below.
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Diabetes, seizures, heart conditions, hypoglycemia, any other conditions*
If you answered "yes", please describe in detail in the space provided below.
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Are you currently taking any medication, including prescription medication?*
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Please list the medical reason, dosage and frequency for each medication, including non-prescription medications
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Bringing on program (Yes/No): (Note: if you plan to bring medication, be sure to bring double the amount needed for the length of the program. Give the extra amount to one of your leaders so that if you lose your supply the leader will have the backup.)
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All participants and leaders of Xplore must be fully vaccinated, or have received an official medical exemption from LC prior to the program. If you have received or are applying for an official medical exemption from Covid-19 vaccination, indicate so below. If you will get vaccinated but have not get received or scheduled the final dose, write "unknown". Otherwise, list the date you received or are scheduled to receive your final dose.
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If you cannot remember, was it within the past five years?
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Are you currently, or do you have a history of treatment or counseling with a mental health professional?*
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Do you have medical insurance through Lewis & Clark College?*
If you will have LC insurance in the fall, mark "yes."If not, please bring your insurance card (or a copy of it) on the program.
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Food preferences: are you a vegetarian?*
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Are you a vegan?*
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Are you gluten-free?
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Do you eat dairy products?*
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Do you eat eggs?*
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Do you eat beef?*
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Do you eat chicken?*
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Do you eat pork?*
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Do you eat fish?*
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Swimming ability*
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Do you exercise regularly?*
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Do you smoke? (Note: answering "yes" will not affect your eligibility.*
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If you don't have a physician, write "N/A"
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Please read carefully: I understand that if I have the potential for a severe allergic reaction to bee stings, insect bites, food, poison oak, or other substances that might be found in the outdoors, it is my responsibility to bring the proper medication with me on this program. I certify that all the information I've given about me on this form is true to the best of my knowledge. By clicking "yes" below, I am signing in agreement that these last two statements are true.*
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