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Student Recreation and Wellness Services
Health History Form

This trip/program involves participation in activities which are, by nature, physically demanding, and often times take place in remote locations without the opportunity for immediate medical attention. As a participant of a Student Recreation and Wellness Services Trip we require full disclosure of your current health. The information you provide is essential, as it may assist with your care in the event of an accident. Full and accurate completion of all sections is very important. The provided information will be kept confidential between the trip leader(s), and health care professionals in the event of an accident.

This form is not used to evaluate your ability to participate in any activities. Only qualified health care professionals can make that decision.

First and Last Name: * Please enter your name.

Date of birth: *

Please enter valid date.

Gender: * Please select one here.

Email: * Please enter your email.

Please fill in Address: *

Please enter address.

Phone number: * Please enter your phone number.

__________________________________________________________________

Medical Insurance Information

Each participant is strongly encouraged to be covered by his/her own health insurance. The University of Akron, Student Recreation and Wellness Services, and Outdoor Adventure do not provide sickness, health, or accident insurance.

_________________________________________________________________

Insurance Provider: * Please enter your answer here.

Insurance Policy/Group #: * Please enter your answer here.

Do you have any physical disabilities or conditions that might limit your participation? *

Yes

Please select at least one choice above.

If yes, please describe: Please enter your answer here.

Are you currently under treatment for any illness or medical condition? *

Yes

Please select at least one choice above.

If yes, please list and describe. Please enter your answer here.

Do you regularly take or need to carry medications? *

Yes

Please select at least one choice above.

If yes, please list and describe. Please enter your answer here.

Do you have any allergies? *

Yes

Please select at least one choice above.

If yes, please list and describe. Please enter your answer here.

Are you allergic to bee or insect stings? *

Yes

Please select at least one choice above.

If yes, please list and describe. Please enter your answer here.

Have you had a cold or heat injury? (i.e. frost bite, hypothermia, heat exhaustion) *

Yes

Please select at least one choice above.

If yes, please describe. Please enter your answer here.

Do you have a history of heart problems? *

Yes

Please select at least one choice above.

If yes, please describe. Please enter your answer here.

Have you undergone surgery within the past year? Or have any open wounds? *

Yes

Please select at least one choice above.

If yes, please describe. Please enter your answer here.

Any dietary restrictions? (dairy, vegetarian, gluten, etc.) Please enter your answer here.

Check any of the following that apply to you: *

Current smoker

Wear glasses or contacts

Have dentures /false teeth

Can swim

Certified in First Aid and/or CPR

None of the above

Please select at least one choice above.

Emergency Contact First & Last Name: * Please enter your name.

Emergency Contact Phone number: * Please enter your phone number.

Your signature *

Click to sign

Please sign here.

Put digital health waivers on your business.

Student Recreation and Wellness Services Health History Form

This form is not used to evaluate your ability to participate in any activities. Only qualified health care professionals can make that decision.

Student Recreation and Wellness Services
Health History Form