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College Outdoors

Peru Trek Health & Diet Questionnaire

The following information is for our trip leaders’ file only and remains strictly confidential.  

It is critical to fill out the health and diet questionnaire thoroughly indicating all current medications, past injuries, and any present conditions.  Failure to do so could put yourself or other participants at risk.  

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(Only required for current students)
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(i.e. 5ft 6in)
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(i.e. 135lbs)
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Gender*
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For example, he/him, she/her, they/them
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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. For each item that you answer "yes", please describe in detail in the space provided below.

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Chronic illness*
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Recent surgeries (in the last two years)*
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Asthma or respiratory issues*
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High blood pressure*
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ADD, ADHD, Asperger's, Depression, Bipolar, or other mental health issues*
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Bone fractures, ligament or tendon injuries*
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Back, shoulder, knee, ankle, any other joint injuries*
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Diabetes, seizures, heart conditions, hypoglycemia, any other conditions*
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Note: Due to the nature of outdoor trips and the distance and time to definitive medical care, we may (in the case of medical conditions that could put you at serious risk in a remote setting) ask you to discuss the trip you're applying for with your physician for their advice and require their permission to place you on the trip.
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Have you ever experienced Acute Mountain Sickness, also known as Altitude Sickness?
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Are you currently taking any medication, including prescription medication?*
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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.)
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If you cannot remember, was it within the past five years?
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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 kori@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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Do you eat Gluten?
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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. Please remember though, College Outdoors trips are smoke-free.)*
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Have you participated in any extended outdoor excursions, programs, or courses?*
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Have you ever spent time at elevations above 10,000ft?
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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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