Student's name _____________________________ Course_______________ Prof.___________
 

While this form is optional it is in your best interest to provide information regarding your health to assure the safest possible field experience.
 

I have already completed this form for another class. You have my permission to obtain this information from Professor ______________________ in the _______________________Department.
 

Medical History (Please check all that apply).
 

Asthma Single organ (kidney, eye) Anemia

Hyperventilation Splenectomy Bleeding disorder

Fainting Hepatitis Chronic depression

Hypoglycemia Recent surgery (past year) Stomach ulcers

Epilepsy/convulsions Neck/back injuries Diabetes

Heart murmur Broken bones (past year) Thyroid disease

Heart valve defect Mononucleosis (in past 6 mos.) Dizziness

Congenital heart problems Collapsed lung

Palpitations Raynaud's disease
 

Chronic illnesses ______________________________________________________________________

Prescription medications___________________________________________________________________

Allergies

Bees/insects Poison ivy/oak Tetanus Toxoid

Medication ___________________________________________________________________________

Food ________________________________________________________________________________
 

When was your last Tetanus shot? ________________________(year)  *If greater than 10 years, must have a booster before field trip. If greater than 5 years, booster highly recommended if trip will be outdoors.

 
 

Do you have any illness or injury presently? Yes No

If yes, list _________________________________________________________________________________
 

Are there any other medical conditions we should be aware of prior to the field trip? Yes No

If yes, explain ______________________________________________________________________________
 
 

FIELD TRIP CHECK LIST
 
 
 

EMERGENCY NOTIFICATION: (Parent or Guardian)
 

Last name ___________________________________ First name ________________________
 

Address _________________________________________________________________________________
 

City/State______________________________________________Zip________________________________
 

Telephone # Home (_____)______-________ Work (______)_______-____________
 

INSURANCE INFORMATION
 

Name of Insurance Company ___________________________________________________________________

Insurance numbers (please give all numbers listed)___________________________________________________
 

Do you belong to a pre-paid health plan, or Health Maintenance Organization? Yes No

Do they need to be called to authorize an ER visit? Yes No

If yes, please provide telephone number of Health Plan. (________)________-__________
 
 
 

I have responded to the above questions truthfully and to the best of my knowledge

I am medically unable to participate in this field trip.

Give reason _____________________________________________________________________
 

I was given the opportunity to complete this health form and chose not to.
 
 
 

fieldtrp.cck 6/97
 

Reviewed by _________________________