Upload File

medical exam (to be filled out by a physician, lnp, or pa) · 2019. 12. 15. · updated &...

  • Home
  • Documents
  • Medical Exam (to be filled out by a Physician, LNP, or PA) · 2019. 12. 15. · Updated & Revised 11/1/2017 Page 1 Medical Exam(to be filled out by a Physician, LNP, or PA) IMPORTANT
2
Updated & Revised 11/1/2017 Page 1 Medical Exam (to be filled out by a Physician, LNP, or PA) IMPORTANT NOTE REGARDING THE MEDICAL EXAM: Applicants may wait until they receive preliminary acceptance into the program to obtain a medical exam (acceptances will be announced April 3). For applicants who are offered a position in the program, medical exams are due on April 17 th . If you choose to wait to get a medical exam, please be sure to still schedule it now. Applicants will not be fully accepted into the program until the NatureBridge medical form is reviewed and approved by NatureBridge staff; those who are given preliminary acceptance but have not submitted their NatureBridge medical exam by April 17 th will forfeit their position in the program. *** This form must be used – alternate forms will not be accepted. *** This page is to be completed and signed by a Physician, Licensed Nurse Practitioner, or Physician’s Assistant. To the examining physician: Our summer backpacking program is strenuous. We hike approximately 5-10 miles (8-16 km) daily at high altitudes (8,000 ft./2,500 m) with 30-50 pound (13-18 kg.) packs. Our participants can be far removed from hospital-based medical support services and as much as 48 hours from definitive care. Your careful examination is an important part of our medical screening process. By signing this form you indicate that the participant is in good physical condition, adequate for successfully participating in our strenuous summer backpacking trips. Please fill out completely. Exam Date____________________ NOTE: Exam must take place within one year of program start date. Patient’s Name _________________________________________________________________ Height _________ (circle ft./cm.) Weight _____ (circle lbs./kg.) Blood Pressure _______/_______ Pulse____________ Circle if normal, describe only if abnormal: Eyes __________________________________________ Ears ___________________________________________ Nose _________________________________________ Throat & Mouth _________________________________ Thyroid _______________________________________ Lymph nodes ____________________________________ Neck _________________________________________ Back ___________________________________________ Extremities ____________________________________ Shoulders _______________________________________ Knees ________________________________________ Ankles __________________________________________ Feet _________________________________________ Skin ____________________________________________ Heart _______________________________________ Other ___________________________________________ Summary of Active Medical Problems and Restrictions Please list below or circle: None _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ To submit, email completed form to [email protected]

Upload: others

Post on 24-Jan-2021

0 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: Medical Exam (to be filled out by a Physician, LNP, or PA) · 2019. 12. 15. · Updated & Revised 11/1/2017 Page 1 Medical Exam(to be filled out by a Physician, LNP, or PA) IMPORTANT

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 [email protected]

Page 2: Medical Exam (to be filled out by a Physician, LNP, or PA) · 2019. 12. 15. · Updated & Revised 11/1/2017 Page 1 Medical Exam(to be filled out by a Physician, LNP, or PA) IMPORTANT

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:


Database Administration Manual - LNP · Database Administration Manual - LNP ... Database Administration Manual - Gateway Screening, or the LNP Feature Activation Guide. When procedures

[LNP] Toradora! Vol.1 Cap.5

NSPManagement Plans for LNP

Lnp Election Review

Database Administration Manual - LNP - Oracle

The LNP Standard Edition 3

The LNP Standard Edition 1

Case study lnp

[LNP] SAO Vol.1 Cap.16

[LNP] Durarara!! Gaiden 01

LNP Nieuwbouwdag

[LNP] SAO Vol.4 Cap.8

The LNP Standard Edition 4

Brochure boschetto mai lnp

e-broucher LNP

Gamme de produits - Chase PlasticsLNP™ KONDUIT™ compound LNP™ LUBRICOMP™ compound LNP™ LUBRILOY™ compound LNP™ STAT-KON™ compound LNP™ STAT-LOY™ compound LNP™

[LNP] SAO Vol.3 Cap.4

THERMOPLASTIC DISTRIBUTION - Industrial … KONDUIT * Compounds LNP* LUBRICOMP * Compounds LNP* LUBRILOY * Compounds LNP* STAT-KON* Compounds LNP* STAT-LOY* Compounds LNP* THERMOCOMP

Lnp 03.01 Penyelenggaraan Sistem Klac

Suplemento Malvinas LNP by DoNgAtO22

The LNP Standard Edition 2

Línea de Productos...LNP™ KONDUIT™ compound LNP™ LUBRICOMP™ compound LNP™ LUBRILOY™ compound LNP™ STAT-KON™ compound LNP™ STAT-LOY™ compound LNP™ THERMOCOMP™

[LNP] SAO Vol.1 Cap.3

Oracle Communications EAGLE LNP Application …...E76223 Revision 3 Oracle® Communications EAGLE LNP Application Processor Administration and LNP Feature Activation Guide Release

[LNP] SAO Vol.1 Cap.5

LNP COL 2.2-1

06 - GROWTH DIAGRAM - GIRLS Name - Prix de Lausanne · Document to return to the consultant-physician of the Prix de Lausanne Information form to be filled in by your attending physician

Prescription Drug Claim Form (updated 1/20)Rx no. Medication name* Medication strength* New prescription Refill Physician name Physician NPI number Date filled (mm/dd/yyyy)* National

LNP Edizione Speciale

LNP Annual Report 2015

Dry and moist dynamics shape regional patterns of extreme … · Correspondingly, the dry/moist decomposition can be applied to the EPS ( lnP): lnP = lnP D + ln(1+ ), [1] where lnP

[LNP] Toradora! Vol.1 Cap.4

[LNP] Toradora! Vol.1 Cap.2

LNP Wedding Welcome Magazine

Joint Health - David Wolfe (LNP)