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Outdoor Leadership Studies Minor
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Medical Emergency and Health Intake form

Health Intake Form 2023

Personal Information

First Name *

Middle Initial

Last Name *

Date of Birth *

Age *

Gender *

Weight (Pounds) *

Height (Feet and Inches) *

Blood Type (Leave blank if not known)

Address *

City *

State *

Zip Code *

WNMU W#

Email Address *

Phone Number *

Emergency Contact

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone Number *

Secondary Emergency Contact Name

Secondary Emergency Contact Relationship

Secondary Emergency Contact Phone Number

Current Health Status

Please indicate if you have any medical conditions or physical disabilities that could interfere with or limit your participation in the trip. If you are unsure, explain the trip to your physician and ask for their advice. If you answer yes to any of the questions below, please describe in detail.

Hearing or Vision Problems (do not include wearing glasses or contacts) *

Yes

No

Respiratory Problems - Including Asthma *

Yes

No

Back Problems *

Yes

No

Joint Problems (e.g. knees, ankles, hips) *

Yes

No

Have you ever dislocated any joint? (e.q. shoulder, knee) *

Yes

No

Serious illness or hospitalization within the last year *

Yes

No

Surgeries in the last 6 months *

Yes

No

Heart Problems *

Yes

No

High or low blood pressure *

Yes

No

Frequent muscle cramps *

Yes

No

Serious reaction to high or low temperatures *

Yes

No

High or low blood sugar/diabetes *

Yes

No

Migraines or frequent headaches *

Yes

No

Psychological or emotional problems *

Yes

No

Seizure Disorders *

Yes

No

Substance Abuse *

Yes

No

Anemia or other bleeding disorder *

Yes

No

Tuberculosis *

Yes

No

Hepatitis *

Yes

No

HIV+ *

Yes

No

Other

If you answered "Yes" to any of the above questions, please describe in detail. *

Allergies

Please indicate any known allergies that you have (medications, foods, etc.). Also, list any allergic reactions and medications required.

Allergy

Reaction

Medications required (if any)

Add Allergy Remove Allergy

Please indicate specific dietary restrictions (lactose intolerance, vegetarian, vegan, kosher, gluten-free, etc.)

Medications

Please indicate any medications you are currently taking (other than allergy medications), for what condition, and whether you will need to take them during the trip.

Medication

Condition

Do you need to take this during the trip?

Yes

No

Add Medication Remove Medication

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Let's get started!

Have questions? Need more information? We are happy to help! Call the Outdoor Program at (575) 538-6253. The WNMU Outdoor Program is operating under a Special Use Permit with the USDA Forest Service in the Gila National Forest.

Outdoor Leadership Minor Undergrad Admissions About the Gila National Forest Department of Natural Sciences

Contact Us

Full Name *

Email *

Message *

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Western New Mexico University P.O. Box 680, Silver City, NM 88062 1-800-872-9668 wnmu.edu

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