Physician`s Health Evaluation Form

Physician’s Health Evaluation Form
Participant: ___________________________________________ Date of Birth_________________
Instructions for Participants:
1. Complete all information on the Personal Health History form for South Jordan Highland Stake
2015 Pioneer Trek and take it to your physician for review along with this form.
2. The Physician’s Health Evaluation Form must be signed by a physician (MD, DO, NP, or PA-C)
within six months prior to embarking on the trek.
3. Sign the “Authorization to Release Information” below (If under age 18, must have parent sign).
Instructions for Physicians:
1. The above named person will participate in a Pioneer Trek Youth Conference June 24-27th,
2015. Persons suffering from any of the conditions listed on the Personal Health History form
must obtain a physician’s clearance before participating in this program. The participants will be
in a wilderness setting for four days. They will have ample food and water. On the first day they
will hike approximately 10 to 12 miles on varying terrain. On subsequent days they will hike
approximately 2 to 8 miles on varying terrain and engage in other outdoor activities. Please
consider the participant’s overall physical and mental condition in your decision (as well as other
medical problems which may be aggravated by or interfere with the participant’s conditions).
2. The Physician’s Health Evaluation Form must be signed by a physician (MD, DO, NP, PA-C)
within six months prior to embarking on the trek. An examination by any other practitioner is not
acceptable.
3. Please perform a thorough physical examination to ensure that participant will receive trek
assignments in which they can succeed. It is unfortunate when a participant must return home
early because of problems that could have been avoided or stabilized before the trek.
4. Don’t sign the Physician’s Health Evaluation Form without reviewing the Personal Health
History form for the South Jordan Highland Stake 2015 Pioneer Trek.
5. Please mark the appropriate box indicating the participant’s overall ability to function on the
pioneer trek.
Authorization to Release Information:
I authorize the examining physician to release the information contained in my personal history and health
evaluation to the South Jordan Highland Stake 2015 Pioneer Trek Committee. I understand that this
information will be reviewed by a physician, and will be used in assessing my level of participation. I
hereby release the examining physician from all legal liability that may arise from the release of or use by
the South Jordan Highland Stake 2015 Pioneer Trek Committee or its agents.
____________________________________________________
Signature of participant (if under age 18 must have parent sign)
_______________________
Date
Participant Fitness Report: Overall Functional Ability
Based on a review of the participant’s history, my personal interview, and a physical examination, the
participant’s ability to function on this Pioneer Trek activity is indicated by an X in the appropriate box.



Full.
May participate without limitations or restrictions.
Partial. May only participate with the following restrictions and/or accommodations.
_____________________________________________________________________________
None. Conditions exist which would make trek participation inappropriate for this candidate.
___________________________________ ___________________________________ _____________
Physician’s Signature
Address (number and street)
Physician’s Name (Print)
City
State
Zip
Date
Telephone (include area code)