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College Outdoors

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 students at risk.  

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7 digits, beginning with a 2. This can be found by logging in to your Pioneer Portal.
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xxx-xxx-xxxx
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(For New Student Trip registration, "NST" is sufficient)
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(i.e. 5ft 6in)
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(i.e. 135lbs)
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For example, he/him, she/her, they/them
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Sex*
Needed in case of necessary medical care
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Allergies

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Do you have any allergies?*
Include any allergies to insects, food, medicines, pollen, etc., as well as any food intolerances. If no, skip to the next section.
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Severity
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Medical Conditions

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Please select Yes or No for each of the following conditions. If 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*
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High blood pressure*
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Anxiety, Depression, ADD, ADHD, Asperger's, 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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Medications

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Are you currently taking any medications?*
Include prescription and non-prescription medication
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Include prescription and non-prescription medication
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list dosages in the same order that you listed medications, separated by a semicolon.
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list frequency in the same order that you listed medications, separated by a semicolon.
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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. If you have a current prescription for an inhaler or epipen, please plan to bring those medications even if yo do not anticipate needing them.
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If you cannot remember, was it within the past five years?
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Mental Health

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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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Diet & Activity

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There's an additional /day charge to provide vegan meals or non-medical specialty diets for New Student Trips in August. This fee IS waived for any medically-based allergies or intolerances. We may ask you to send us a note from your health care provider. Vegan and gluten-free meals are not available for all trips New Student Trips, please check the trip descriptions. Vegetarian diets do not have an additional fee.

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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. Please remember though, College Outdoors trips are smoke-free.)*
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Have you participated in any extended outdoor programs or courses?*
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Emergency Information

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Do you have medical insurance through Lewis & Clark College?*
If you are registering for a New Student Trip and will have L&C for the fall term, select "yes." 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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If applicable
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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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