Volunteer Health Form

Therapeutic Adventures, Inc.

CONFIDENTIALITY/PRIVACY NOTICE – This document contains information that is confidential and/or legally privileged. The contents provided are intended to provide registered Therapeutic Adventures – instructors/adaptive guides with necessary information so that programs can be safely administered.

Name

First

Middle

Last

HEALTH / MEDICAL INFORMATION

Currently taking any medications?

Yes
No

If YES, please list all, including over-the-counter medications:

Have you had surgery in the last 6 months?

Yes
No

If YES, please describe.

If Specify: any

Have you ever had a serious disease?

Yes
No

If YES, please describe.

MEDICAL HISTORY

Please Specify:

Please check any that apply. If YES, please describe below.

Amputation (Lower Extremity)
Amputation (Upper Extremity)
Blind / Visual Impairments
Deaf / Hearing Impairment
Post Concussion Syndrome (1, 2, 3, or more concussions, please specify)
Traumatic Brain Injury (TBI)
Traumatic Spinal Cord Injury (paraplegia, quadriplegia)
Traumatic Stress Disorder (PTSD)
Other (specify)

Please Describe:

LIMITATIONS FOR ACTIVITY

Has any physician advised you to limit your activity?

Yes
No

If YES, please describe:

Do you have a Hx of any back, shoulder, knee, or other joint problems?

Yes
No

If YES, please describe:

Please indicate the contraindications for activity that will require special attention?

Emergency Information

(Person to notify in the event of an emergency)

Primary Contact

First

Last

Phone

Secondary Contact

First

Last

Phone

Permission to Obtain Emergency Medical Care

In the event of a medical emergency, I authorize Therapeutic Adventures staff to hospitalize, to secure proper medical treatment, and/or order injections, anesthesia or surgery for me.

Name

First

Last

Date