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Pathways to Success in STEM

Health & Diet Questionnaire

**Only students who have been accepted to the program via our application process may register! Please do not complete these forms if you have not been accepted to the program.

Forms will be available after May 8, 2018.

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.

Student ID Number

Look for it on your Admissions letter. If you can't find it, please enter "Don't Know."

Your first & last name*

Do you have any allergies (to insects, food, medicines, pollen, etc.) or food intolerances?*

Yes

No

If yes, please describe - Allergen/Intolerance:

Severity

Mild Rash

Severe Rash

Potential to disrupt breathing

Other

If other, please describe

Please check Yes or No to the following conditions: Chronic illness*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

Recent surgeries (in the last two years)*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

Asthma*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

High blood pressure*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

ADD, ADHD, Asperger's, Depression, Bipolar, or other mental health issues*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

Bone fractures, ligament or tendon injuries*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

Back, shoulder, knee, ankle, any other joint injuries*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

Diabetes, seizures, heart conditions, hypoglycemia, any other conditions*

If you answered "yes", please describe in detail in the space provided below.

Yes

No

Please describe below any of the conditions you checked "yes" to, and/or describe any other conditions not listed above. For injuries and/or recent surgery, please list the date of injury or operation and your present degree of recovery.

Are you currently taking any medication, including prescription medication?*

Yes

No

Please list any medications, including all prescription medications, you currently take and/or will take by the time of your trip. Medication:

Dosage for each medication listed:

Frequency of dosage for each medication listed:

Bringing on trip (Yes/No): (Note: if you plan to bring medication, be sure to bring double the amount needed for the length of the trip. Give the extra amount to your trip leader so that if you lose your supply the leader will have the backup.)

Year of last tetanus immunization*

If you cannot remember, was it within the past five years?

Yes

No

Are you currently, or do you have a history of treatment or counseling with a mental health professional?*

Yes

No

If yes, please describe:

Do you have medical insurance through Lewis & Clark College?*

If no, please either complete the information below (some fields may not apply), email a scan of both sides of your card to outdoors@lclark.edu, or, if you are on campus, bring your medical insurance card to the College Outdoors office in Templeton 244.

Yes

No

Name of insurance company:

City/State:

Group number:

Plan number:

Personal/Member ID number:

Policy/Certificate ID number:

Authorization phone number:

Your date of birth:*

Food preferences: are you a vegetarian?*

Yes

No

Are you a vegan?*

Yes

No

Do you eat dairy products?*

Yes

No

Do you eat eggs?*

Yes

No

Do you eat beef?*

Yes

No

Do you eat chicken?*

Yes

No

Do you eat pork?*

Yes

No

Do you eat fish?*

Yes

No

Please list below any foods you particularly despise. We'll try to avoid these when planning the menu!

Swimming ability*

Non-swimmer

Infrequent

Recreational

Strong swimmer

Competitive

Do you exercise regularly?*

Yes

No

If yes, please describe. Activity:

Frequency/duration:

Intensity: (easy, moderate, competitive)

Do you smoke? (Note: answering "yes" will not affect your eligibility.*

Yes

No

Primary contact in case of emergency (a parent, guardian, or close relative). Person's name:*

City/State*

Home phone number (please be sure to fill in at least one contact number)

Business phone number

Cell phone number

Secondary contact in case of emergency (this person should be at a different phone number from the Primary contact). Person's name:*

City/State*

Home phone number (please be sure to fill in at least one contact number)

Business phone number

Cell phone number

Your family doctor - Physician's name:*

City/State*

Business phone number*

Alternative phone number

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 trip. 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.*

Yes

No

Date of signature (mm/dd/yy)*

Pathways to Success in STEM

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Contact Us

47
Pathways to Success in STEM is located in room 208 of Albany on the Undergraduate Campus.

email sponsres@lclark.edu

voice 503-768-7362 fax 503-768-7105

Julio de Paula:
jdepaula@lclark.edu
Paulette Bierzychudek:
bierzych@lclark.edu

Pathways to Success in STEM
- Pathways to Success in STEMLewis & Clark0615 S.W. Palatine Hill RoadMSC 47PortlandOR97219