/ College Outdoors/ Forms/Health & Diet Questionnaire

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.

All fields marked with asterisk (*) are required.

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Student ID Number*

7 digits, beginning with a 2. This can be found by logging in to your L&C Portal.

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Your first & last name*

List the name you go by and your last name.

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Cell phone number*

xxx-xxx-xxxx

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Name of trip/program*

A general indication of which trip you are signed up for is fine. For example, “coast hike”

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Your height*

(i.e. 5ft 6in)

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Your weight*

(i.e. 135lbs)

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Your date of birth:*

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Gender Identity Pronouns*

For example, he/him, she/her, they/them

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Sex*

Needed in case of necessary medical care

Female

Male

Other

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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.

Yes

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List WHAT you are allergic to / intolerant of, and describe your REACTION to each allergen

If you have been prescribed an inhaler, EpiPen, or other medication for allergies, be sure to bring it on your trip.

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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*

Yes

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Recent surgeries (in the last two years)*

Yes

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Asthma*

If you have been prescribed an inhaler, be sure to bring it on your trip, even if you don’t anticipate needing it.

Yes

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High blood pressure*

Yes

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Anxiety, Depression, ADD, ADHD, Autism, Bipolar, or other mental health issues*

Yes

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Bone fractures, ligament or tendon injuries*

Yes

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

Yes

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

Yes

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Please describe (including severity) 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.

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

Yes

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Please list any medications you currently take and/or will take by the time of your trip. List the MEDICATION, DOSAGE, and FREQUENCY each medication is taken.

Include prescription and non-prescription medication

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Bringing Medication 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 you do not anticipate needing them.

Yes

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Date of final dose of Covid-19 vaccination*

All participants and leaders on College Outdoors trips must be fully vaccinated, including a booster dose. If you have received an official exemption from LC, you can participate in on-campus outdoor activities, but not attend off-campus trips that involve driving in an enclosed van.

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Year of last tetanus immunization (if you know it)*

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

Yes

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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?*

Yes

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If yes, please describe:

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Diet & Activity

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There’s an additional charge per day to provide vegan meals or non-medical specialty diets for New Student Trips in August and for Spring Break Trips. 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. Vegetarian and religious diets do not have an additional fee.

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Are you a vegetarian?*

Yes

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Are you a vegan?*

Yes

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Are you Gluten-Free?*

Use the text box below to indicate if your level of sensitivity to gluten

Yes

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Do you eat dairy products?*

Yes

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Do you eat eggs?*

Yes

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Do you eat beef?*

Yes

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Do you eat chicken?*

Yes

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Do you eat pork?*

Yes

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Do you eat fish?*

Yes

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Please list below any relevant details about your dietary restrictions, and also list any foods you particularly despise. We’ll try to avoid these when planning the menu!

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Swimming ability*

Non-swimmer

Not strong/confident

Recreational

Strong swimmer

Competitive

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Do you exercise regularly?*

Yes

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If yes, please describe the ACTIVITY, FREQUENCY you do it, and INTENSITY at which you perform the activity (easy, moderate, competitive)

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Do you smoke or vape?*

Note: answering “yes” will not affect your eligibility. Please remember though, College Outdoors trips are smoke & vape-free.

Yes

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If yes, how much/how frequently?

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Have you participated in any extended outdoor programs or courses?*

Yes

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If yes, please specify the program and duration:

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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 insure for the fall term, select “yes.” If no, it is critical that you bring your insurance card (or a copy of it) on your trip.

Yes

No, but I will bring my insurance card on the trip

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

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Primary contact’s relationship to you

i.e. parent, friend, guardian, sibling, etc

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City/State*

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Primary phone number*

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Alternate phone number

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Business phone number

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

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Secondary contact’s relationship to you

i.e. parent, friend, guardian, sibling, etc

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City/State*

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Primary phone number*

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Alternate phone number

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Business phone number

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Your family doctor - Physician’s name:*

If you don’t have a physician, write “N/A”

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City/State

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Business phone number*

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Alternative phone number

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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 or otherwise encountered on trips, 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

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Date of signature (mm/dd/yyyy)*

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