For NOLS Office Use Only Initial Review OK Detailed Review OK Check ...

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Health Form.06 10/17/05
© 2006 National Outdoor Leadership School 1 H E A L T H F O R M

For NOLS Office Use Only Initial Review OK Detailed Review OK Check Further Date / / AO Initials

Student’s Name Course Code Application ID#
( ) ( )
Daytime or Temporary Phone (circle one) Permanent Phone


Gender Age NOLS Grad Non-Grad
NOLS Expedition Information for the Medical Professional
National Outdoor Leadership School (NOLS) courses are wilderness expeditions, varying in length
from eight days to three months. NOLS expeditions operate in remote areas where evacuation to
modern medical facilities may take days.

Weather conditions can be extreme with temperatures ranging from –40° F to +100° F. Prolonged
storms, high winds, intense sunlight, sudden immersion in cold water and/or high seas are possible.

Physical demands on the applicant may include carrying a backpack weighing between 55-85 pounds
over uneven terrain such as snow, rocks, boulders, fallen logs, or slippery surfaces as well as
ascending and descending steep mountain slopes. Elevations for backpacking courses range from sea
level to 12,000 feet. Peak climbs on mountaineering courses may be as high as 14,000 feet. The India
and Denali expeditions may reach elevations of 18,000 feet and 20,000 feet respectively. Physical
demands of sea kayaking and river courses require paddling heavily loaded kayaks, canoes or rafts
and lifting and carrying boats over uneven terrain.

While participating on a NOLS expedition, students will sleep outdoors, experience long physically
demanding days, set up their own camp and prepare their own meals. Each student is expected to
take good care of him or herself. On some courses, students may have the option to fast without food,
for up to five days.

NOLS disinfects all wilderness water with iodine, chlorine, chlorine dioxide or by boiling. Not all of
these methods are effective against cryptosporidium. Immunocompromised people may wish to
obtain an appropriate water filter for their course.

NOLS is not a rehabilitation program. NOLS is not the place to quit smoking, drinking or drugs or to
work through behavioral or psychological problems.

Prior physical conditioning and an enthusiastic mental attitude are a necessity. Students find a NOLS
course to be an extremely demanding experience both physically and emotionally.
Health Form.06 10/17/05
© 2006 National Outdoor Leadership School 2 In the interest of the personal safety of both the applicant and the other expedition members, please
consider the questions carefully when completing the health form. A "Yes" answer does not
automatically cancel a student’s enrollment. If we have any question on the student’s capacity to
successfully complete the course we will call the student to discuss it.

The applicant is not accepted on the course until the health form has been reviewed and
approved by NOLS admissions personnel. Your detailed comments will expedite our review of this form. Physician, F.N.P. or P.A.:
Please check YES or NO for each item. Each question must be answered and please provide date and
details for all "yes" answers.

General Medical History
Does the applicant currently have or have a history of:
1. Respiratory problems? Asthma? YES NO Is the asthma well controlled with an inhaler? YES NO If so, please have the student bring inhaler(s) with them for their course . What triggers an attack? Last episode? Ever hospitalized?




2. Gastrointestinal disturbances? YES NO 3. Diabetes? YES NO Examiner’s specific comments:




4. Bleeding, DVT (deep vein thrombosis) or blood disorders? YES NO 5. Hepatitis or other liver disease? YES NO Examiner’s specific comments:




6. Neurological problems? Epilepsy? YES NO 7. Seizures? YES NO 8. Dizziness or fainting episodes? YES NO 9. Migraines? Medications, frequency, are they debilitating? YES NO 6-9. Describe frequency, date of last episode, and severity. ?




10. Disorders of the urinary or reproductive tract? YES NO 11. Any disease? YES NO 12. Does this person see a medical or physical specialist of any kind? YES NO If "yes" please specify the issue(s) and provide name/address of specialist.





Health Form.06 10/17/05
© 2006 National Outdoor Leadership School 3
Questions 13 and 14 Are For Female Students Only:

13. Treatment or medication for menstrual cramps? YES NO 14. Is she pregnant? YES NO Examiner’s specific comments: ?




15. Hypertension? YES NO 16. Cardiac problems? Unexplained chest pain? YES NO Examiner’s specific comments:




Cardiac Screening: A stress ECG is required if the applicant is: Cardiac Risk Factors 1. Over 35 years old and has 2 cardiac risk factors. 2. Over 50 years old and has 1 cardiac risk factor. 3. Over 50 years old and leads a sedentary lifestyle. 4. Any age with a known heart condition.

Please provide a written note from your doctor
stating the date of the stress ECG and the
results. • High blood pressure • Diabetes • Current or prior cardiovascular disease • High blood cholesterol • Family history of heart disease (family
member who’s had a heart attack at
less than 55 years of age). • Smoking
The stress ECG requirement may be waived for applicants who are over 50 years of age with no
cardiac risk factors and who are in good physical condition. Their physician must note that the
applicant has a) no cardiac risk factors and b) excellent cardiac health on page 6 of this form.

Muscle/Skeletal Injuries/Fractures
Does the applicant currently have or does he/she have a history within the past 3 years of:
17. Knee, hip or ankle injuries (including sprains) and/or surgery? YES NO Type of injury or surgery? When did the injury or surgery occur?




Is there full ROM? Full Strength? YES NO What is the most rigorous activity participated in since the injury/surgery. Results?




Examiner’s specific comments: (include date of last occurrence and the effect of the problem on
current activity level)




Health Form.06 10/17/05
© 2006 National Outdoor Leadership School 4

18. Shoulder, arm or back injuries (including sprains) and/or surgery? YES NO Type of injury or surgery? When did the injury or surgery occur?



Is there full ROM? Full Strength? YES NO What is the most rigorous activity participated in since the injury/surgery. Results?

Examiner’s specific comments: (include date of last occurrence and the effect of the problem on current
activity level):

19. Any other joint problems? YES NO Examiner’s specific comments: (include date of last occurrence and the effect of the problem on
current activity level)



20. Head Injury? Loss of consciousness? For how long? YES NO Examiner’s specific comments: (include date of last occurrence and the effect of the problem on
current activity level)



21. Does the applicant have any physical, cognitive, sensory or emotional condition that would require
a special teaching environment? YES NO If yes, please describe how the condition effects you:



Personal History(Counseling/Psychiatric/Learning Disabilities)
NOLS requires that any student with a counseling history demanding medication, hospitalization or
residential treatment, display one year of stability before they will be accepted for a course. They must
be successfully employed or in school.

22. Has he/she had treatment, counseling or hospitalization with a mental health professional?
YES NO 23. Is he/she currently in treatment or counseling? YES NO 24. Reasons for treatment or counseling?
suicide ADD/ADHD substance abuse/chemical dependency family issues/divorce eating disorder (anorexia/bulimia) depression academic/career other
Please Provide Specific Dates and Details of Counseling Hx and medications that were prescribed:



25. Name, address and telephone number of therapist?
( )
Name Phone
Street Address State Zip Health Form.06 10/17/05
© 2006 National Outdoor Leadership School 5
Allergies
26. Is he/she allergic to any foods? YES NO Describe:

27. Are there any dietary restrictions? Please specify. YES NO vegetarian vegan other

28. Allergic to insect bites or bee stings? YES NO If appropriate please bring 2-3 Epi Pens or Twinjects.
Examiner’s specific comments:



29. Any other allergies? YES NO Examiners Specific Comments:



30. Water may be disinfected with iodine. Is iodine contraindicated? YES NO
Medications
31. Is he/she allergic to any medications? YES NO If yes, please list:



32. Does this person plan to take any prescription or non-prescription medications on the course? YES NO NOLS courses travel in remote areas where access to medical care may be one or more days
away. The student must understand the use of any prescription medications they may be
taking. Written specific instructions are necessary. All Students who are required by their
personal physician, psychiatrist or health care provider to take prescription medications on a
regular basis must be able to do so on their own and without additional supervision.
Medication Dosage Side Effects/Restrictions Prescribed by? For What Conditions?



If Medication or Condition Changes Prior to Course Start, Please Inform NOLS.

Cold, Heat, Altitude
33. History of frostbite or Raynaud’s Syndrome? YES NO 34. History of acute mountain sickness, high altitude pulmonary/cerebral edema?
YES NO When did the illness occur?



35. History of heat stroke or other heat related illness? YES NO Examiner’s specific comments:



Health Form.06 10/17/05
© 2006 National Outdoor Leadership School 6 Fitness (please provide details concerning the students exercise regime)
36. Does the applicant exercise regularly? YES NO Activity Frequency
Duration/Distance Intensity Level Easy Moderate Competitive
Activity Frequency
Duration/Distance Intensity Level Easy Moderate Competitive

37. Does this person smoke? If so how much? YES NO There is no smoking allowed on NOLS courses. We recommend that applicant quit now.

38. Is this person overweight? Underweight? If so, how much? YES NO
39. Swimming ability (CHECK ONE): Non-swimmer Recreational Competitive

Physical Examination
Physician must read and fill out pages 1-6. Physical examination data cannot be more than a year
old from the starting date of the NOLS course. (Please type or print legibly)
NOLS Requires a Tetanus Immunization Within 10 Years of the Start Date of the Course. Expeditions Outside the U.S. May Require Additional Immunizations. Please refer to your course
description for specific information.

/ /
Blood Pressure Pulse Last Tetanus Inoculation Height Weight
General Appearance, Impressions and Comments: (If applicable, address cardiac health. See question
#16.) :



( )
Examiner’s Name Phone

Street Address State Zip
/ /
Physician, F.N.P. OR P.A. Signature Date:
By my signature, I attest that the information in this form is correct and the person named
on page one of this form is medically cleared to participate on a NOLS course based on the
expedition information provided on page 1 of this form along with the background
information provided by the applicant and my physical examination of him/her.

Please Return All Six Pages To: NOLS, 284 Lincoln St. Lander, WY 82520

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