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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.

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.

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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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Do you have any allergies (to insects, food, medicines, pollen, etc.) or food intolerances?*
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Severity
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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 answered "yes", please describe in detail in the space provided below.
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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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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 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.
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Food preferences: are you a vegetarian?*
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Are you a vegan?*
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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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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.*
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