Health History Form

Please complete this health history information form. Answering in the affirmative to any of the questions below will not automatically disqualify you from participating in the program.

Please be honest and forthcoming with your answers. Advanced medical care is NOT typically available during the program. JIRP will have medical personnel on hand, and all field staff will have Wilderness Advanced First Aid certification (minimum). The more complete medical information we have on hand, the more optimally we can assist in case of an emergency or medical issue.

Any divulged information will be kept confidential and will not be shared with any outside entity. Information will only be shared with the JIRP staff and medical faculty who have the responsibility to provide medical care. By signing this form, you acknowledge that in the case of medical issue or need for treatment, this medical/health information may be shared with attending JIRP personnel and/or appropriate medical personnel.

Contact Information

Legal Name

First Name

Last Name

Preferred Name

Verify Email

General Information

Gender Identity

Sex Assigned at Birth

Height: Feet

Height: Inches

Weight (pounds):

Birthdate

(mm/dd/yyyy)

Primary Care Provider

Primary Care Provider Name

First Name

Last Name

Primary Care Provider Phone Number

Primary Care Provider Email

Verify Email

Health History

Please explain any relevant answers in the space provided.

Pulmonary Health: Do you have any lung problems, such as asthma, COPD, cystic fibrosis, or any ongoing respiratory issues?

Cardiac Health: Do you have any cardiac or heart conditions such as angina, CHF, coronary artery disease, arrhythmia, or previous cardiac surgery?

Blood Pressure: Do you have either high or low blood pressure?

Dental Health: Do you have any untreated or ongoing dental issues?

Fainting: Have you had fainting spells?

Gastrointestinal Health: Do you have any gastrointestinal issues such as ulcers, GERD, Crohn's disease, ulcerative colitis, or other active condition(s)?

Hepatitis: Have you had any form of hepatitis?

Musculoskeletal Health: Do you have any musculoskeletal condition such as chronic back or joint pain, arthritis, or joint replacement?

Gynecological Health: Do you have any gynecological issues such as heavy bleeding, endometriosis, or other ongoing problems?

Pregnancy: Do you think you may be pregnant, or are intending to become pregnant before the field season?

Urinary System Health: Do you have any urinary issues such as frequent UTIs, frequent kidney stones, urinary retention, or other ongoing problems?

Oncologic History: Have you ever had any form of cancer, including leukemia or lymphoma?

Dermatologic Health: Do you have any ongoing skin issues such as eczema or psoriasis?

Mental Health: Describe your mental health history. Please include any hospitalizations medications and treatments related to psychiatric conditions such as depression, anxiety, or psychosis.

Infectious Disease: Do you have any persistent or chronic infectious disease?

Hematological Health: Do you have any blood disorder such as anemia, thrombocytopenia, bleeding disorders, or clotting disorders?

Surgical History: Please list all surgeries you have had (including gender affirming care), not including simple skin procedures or dental procedures.

Additional information: If you answered yes to any of the above and would like to share more information, please do so here.

Medications

Please list all medications you take more than twice a month. Please include hormones and over the counter medicines.

For prescription medications, please include dosage amount and frequency.

Medications:

Allergies

Do you have a history of allergy other than simple seasonal allergies ("hay fever")? This includes allergies to medications or food.

If yes, please describe: the allergen, to which methods of contact you've been sensitive in the past (inhalation, skin contact, ingestion, etc.), the severity of your past reactions, the date of your last reaction, and what medical care (if any) was necessary (antihistamines, epinephrine, hospitalization, etc.). *

Allergies:

Vaccination History

Tetanus

Current

Not current, will update if necessary

Don't know

Pertussis (often given in the same shot as Tetanus, known as "Tdap")

Current

Not current, will update if necessary

Don't know

COVID-19

Current (received more recently than September 2023)

Not current, will update before Arrival Day

I am not vaccinated against COVID-19

Don't know

Measles, Mumps, & Rubella (MMR)

Current

Not current, will update if necessary

Don't know

Hepatitis A

Not required, but often given to adults in specific higher risk categories. See cdc.gov/vaccines/hcp/vis/vis-statements/hep-a.html for more information.

Current

Not current

Don't know

Vaccine Exceptions

If you do not have current vaccinations for Tetanus, Pertussis, COVID-19, or MMR, and you do not intend to receive up-to-date vaccinations by the start of JIRP 2024, please explain your reasons in detail here.

Refusing vaccinations may disqualify you from participating in JIRP, depending on the vaccination in question and your circumstances.

Vaccine Exceptions:

Additional Information

If you have any additional conditions or concerns you feel would be important for the program to know, please list and/or explain them here.

Signature

All information provided by me is accurate and correct. I agree to provide follow up information to JIRP in regards to any information disclosed here should it be requested.

I Agree

Juneau Icefield Research Program

Health History Form

Contact Information

General Information

Primary Care Provider

Health History

Vaccination History

Additional Information

Signature