Updated & Revised 11/1/2017 Page 1

MedicalExam(tobefilledoutbyaPhysician,LNP,orPA)IMPORTANTNOTEREGARDINGTHEMEDICALEXAM:Applicantsmaywaituntiltheyreceivepreliminaryacceptanceintotheprogramtoobtainamedicalexam(acceptanceswillbeannouncedApril3).Forapplicantswhoareofferedapositionintheprogram,medicalexamsaredueonApril17th.Ifyouchoosetowaittogetamedicalexam,pleasebesuretostillscheduleitnow.ApplicantswillnotbefullyacceptedintotheprogramuntiltheNatureBridgemedicalformisreviewedandapprovedbyNatureBridgestaff;thosewhoaregivenpreliminaryacceptancebuthavenotsubmittedtheirNatureBridgemedicalexambyApril17thwillforfeittheirpositionintheprogram.

***Thisformmustbeused–alternateformswillnotbeaccepted.***

ThispageistobecompletedandsignedbyaPhysician,LicensedNursePractitioner,orPhysician’sAssistant.

Totheexaminingphysician:

Oursummerbackpackingprogramisstrenuous.Wehikeapproximately5-10miles(8-16km)dailyathighaltitudes(8,000ft./2,500m)with30-50pound(13-18kg.)packs.Ourparticipantscanbefarremovedfromhospital-basedmedicalsupportservicesandasmuchas48hoursfromdefinitivecare.

Yourcarefulexaminationisanimportantpartofourmedicalscreeningprocess.Bysigningthisformyouindicatethattheparticipantisingoodphysicalcondition,adequateforsuccessfullyparticipatinginourstrenuoussummerbackpackingtrips.

Pleasefilloutcompletely.

ExamDate____________________NOTE:Exammusttakeplacewithinoneyearofprogramstartdate.

Patient’sName_________________________________________________________________

Height_________(circleft./cm.)Weight_____(circlelbs./kg.)BloodPressure_______/_______Pulse____________

Circleifnormal,describeonlyifabnormal:

Eyes__________________________________________ Ears___________________________________________

Nose_________________________________________ Throat&Mouth_________________________________

Thyroid_______________________________________ Lymphnodes____________________________________

Neck_________________________________________ Back___________________________________________

Extremities____________________________________ Shoulders_______________________________________

Knees ________________________________________ Ankles__________________________________________

Feet _________________________________________ Skin____________________________________________

Heart _______________________________________ Other___________________________________________

SummaryofActiveMedicalProblemsandRestrictionsPleaselistbeloworcircle:None

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

To submit, email completed form to alcoascholars@naturebridge.org

Updated & Revised 11/1/2017 Page 2

ConditionsandSymptomsDoesthepatienthaveorhavetheyhadanyofthefollowingconditionsorsymptoms?

Ifyouhaveanswered“yes”toanyoftheaboveitems,pleaseexplainbelow.Includethefollowing:

• Whatspecificsymptomsareoccurring

• Howlongsymptom/conditionlasts

• Dateoflastoccurrence • Howoftensymptom/conditionoccurs

• Howyoucareforsymptom/condition

• Howsymptom/conditionrestrictsapplicant’sactivityinanyway(includingapplicant’sabilitytohike)

NOTE:IfPatienthassevereasthmaorsevereallergies,pleaseprovideanasthmaoranaphylaxisemergencyactionplan.

ItemNo. DetailedDescription(includingrestrictions,ifany)

Physician'sSignatureRequiredHowlonghaveyouknowntheapplicant? _______________________________________________________________

NameofexaminingPhysician(pleaseprint): _____________________________________________________________

Address:______________________________________Telephone:________________Fax: _____________________

Physician’sSignature________________________________________Date__________________________________

1. Tuberculosis £Yes£No 11. KidneyInfection £Yes£No 21. Ankleproblem £Yes£No

2. ChronicCough £Yes£No 12. ThyroidProblems £Yes£No 22. Kneeproblem £Yes£No

3. Asthma £Yes£No 13. HearingImpairment £Yes£No 23. Brokenbones £Yes£No

4. Diabetes £Yes£No 14. VisionImpairment £Yes£No 24. Motionsickness £Yes£No

5. Hypoglycemia £Yes£No 15. CirculationProblems £Yes£No 25. Learningdisability £Yes£No

6. RecentexposuretoactiveTB

£Yes£No 16. RespirationIssues £Yes£No 26. MedicalEquipment/Devices

£Yes£No

7. PositiveTBTest £Yes£No 17. Headaches £Yes£No 27. Specialdiet £Yes£No

8. ActiveHepatitis £Yes£No 18. IntestinalProblems £Yes£No 28. Sleepwalking £Yes£No

9. SeizureDisorder £Yes£No 19. BladderInfection £Yes£No 29. Eatingdisorder £Yes£No

10. BleedingDisorder £Yes£No 20. SkinProblem £Yes£No 30. Other: