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MedicalHistory
ProgramEntry-Confidential-
COMPLETETHISFORMANDRETURNTO:
PNWAdult&TeenChallengeRegionalOfficeIntakeCoordinator6902SELakeRoad–Suite300Milwaukie,OR97267Phone:(503)765-5252Fax:(971)[email protected]
Pleasereadcarefullythefollowinginstructions.
1. ThefirsttwopagesconcernthePhysiciansReport.ThefirstpageidentifiestheteststhatmustbeconductedbyaPhysicianandthelabresultssentintoPacificNorthwestAdult&TeenChallengeRegionalOffice6902SELakeRdSuite300,Milwaukie,OR97267orfaxedto(971)254-9892.
2. ThephysicalExamistoruleoutcontagiousdiseasesorsignificantmentalorphysicalimpairment–
similartoasportsphysical–(useDoctor’sforms);3. Thespecificteststobeconductedarelistedbelow:
• Tuberculosistest:PPDorchestx-rayorothertestsasrecommendedbydoctor.• Genitalexam–ifindicatedforsexualtransmitteddiseases;• HIVtest;• HepatitisPanel–Complete(includesA,BandCscreeninglabtest)
4. IftheapplicantistakingaparticularmedicationwhileintheTeenChallengeprogram,theattending
physicianshouldhavesufficientinformationtoverifyitandstatetheprescribedmedicationanddosageonpage2.Thisisamustoryoumaynotbeallowedtotakethemedication.
5. Non-prescriptionItems–Studentsarepermittedtobringnon-prescriptionitemsintotheprogramorreceivethemfromoutsidetheprogram(aspirin,etc.),if,andonlyif,theyareenclosedinthemanufacturersoriginalpackageandthewrappingsealisunbroken–NOEXCEPTIONS.
6. TheMedicalHistoryistobefilledoutbytheapplicantandreturnedtotheaddressbelow.
Theapplicant’ssignaturebelowauthorizesthetestslistedabovetobecompletedandtheresultsandinformationsenttoPacificNorthwestAdult&TeenChallengeRegionalOffice6902SELakeRdSuite300,Milwaukie,OR97267.
Applicant’sName(print): Applicant’sSignature: Date:
PACIFICNORTHWESTADULT&TEENCHALLENGE
PHYSICIANSREPORT
Physician’sReport(continued)
Uponexamination,thepatient’sgeneralphysicalhealthwasfoundtobe:
Good Average Poor
Thepatientisexperiencingamedicalconditionthatrestrictstheirparticipationinphysicallabor.
Yes No
Ifyes,pleaseexplain:
Physician’sAuthorizationofMedication
Listanymedicationprescribedforthepatientbyyouoranotherphysician.Pleaseindicateifanyoftheseprescriptionsarehabitformingtoyourknowledge.
Medication PrescribedFor HabitForming
Yes No
Yes No
Yes No
Yes No
Yes No
Physician’sName(print):
PhoneNumber: FaxNumber:
Address:
Physician’sSignature: Date:
Pleasereturnthisandalltestresultsandinformationto:PacificNorthwestAdult&TeenChallengeRegionalOffice–6902SELakeRd,Suite300,PortlandOR97267Fax(971)254-9892.
PACIFICNORTHWESTADULT&TEENCHALLENGEMEDICALREPORT
ApplicantsName:
Sex: Male Female DateofBirth: Height: Weight:
Married: Yes No Howlong? Nationality:
BloodType:
Currentphysician: Phone:
PacificNorthwestAdult&TeenChallengeiscommittedtohelpingstudentsbecomephysically,mentallyandspirituallywhole.Wearenot,however,amedicalprogram.Wewillendeavortoassistyouinsecuringwhatevermedicalhelpwecanwhileyouareintheprogram.Ifyoubecomeillorneedmedicalattentiononceyouareintheprogramwewillassistinconnectingyouwithamedicalfacility.Youareresponsibleforanyfeesthataccrueinconnectionwithyourvisittooftreatmentfromanymedicalfacility.Wedonotfinanciallyassiststudentsinmeetingtheirmedicalbills.
ExplaininthespacebelowanyprovisionsyouhavetocovermedicalexpenseswhileenrolledinTeenChallenge?
HealthInsurance: Yes No InsuranceCompany:
PolicyNumber: Doesyourpolicyrecognizerecoveryservices? Yes No
Doyoucollectdisabilitypayments? Yes No
EmergencyContactInformation
Name: Phone:
Address: City: State: Zip:
Relationshiptoapplicant:
PersonalMedicalHistory
Areyoucurrentlybeingtreatedbyaphysicianforanillness,injuryormedicalsymptom? Yes No
Ifsopleaseprovidethenameofthephysician:
Address: Phone:
Describeanyillness,injuryorsymptoms:
Areyoucurrentlyreceivingtherapyforanyofthecircumstancesdescribedabove? Yes No
IfYes,pleaseexplain.
Areyouexperiencingorhaveyouexperiencedaninjuryorillnessthataffectsyourabilitytoparticipatein?
ManualWorkExperience
ExercisePrograms
RecreationalActivities
Yes No
Yes No
Yes No
Ifyestoanyoftheabove,pleaseexplain.
Pleaselistanyfoodallergies
Areyouallergictobeestings? Yes No Doyouneedmedicationifstung? Yes No
Areyouallergictoanymedications? Yes No
Pleaseidentifyallmedicationsyouareallergictointhespacebelow.
Checkifyouhave:
HayFever Diabetes Asthma Seizures Epilepsy
Convulsions Blackouts Arthritis Dizziness ChronicFatigue
ChronicBackaches SinusTrouble Migraines BlurredVision DoubleVision
LossofSight LossofHearing EarInfections HighBloodPressure LowBloodPressure
Gonorrhea Syphilis Herpes Aids Chlamydia
Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No
Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequencybelow:
Checkifyouhave: HeartTrouble ChronicCough Hemorrhoids Ulcer’s Jaundice
HeartBurn AcidReflex BlackStool KidneyStones Hepatitis
Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No
Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequencybelow:
Areyouexperiencing: PoorAppetite Nausea Vomiting VomitingBlood
FrequentIndigestion FrequentDiarrhea FrequentConstipation
IntestinalParasites PersistentWeightGain PersistentWeightLoss
CoughingupBlood BloodinUrine FrequentUrination
Bladderinfections ProblemsUrinating SevereItching
ProblemsSleeping Depression Anxiety
Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No
Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequency:
Haveyouhad: Measles ChickenPox ScarletFever WhoopingCough
Mumps SmallPox TyphoidFever Diphtheria
Tuberculosis Pneumonia Cancer Anemia
NervousBreakdown HeadInjury
Areyoucurrentlytakinganymedicationsforanyoftheconditionsmentionedabove? Yes No
Ifso,pleaseidentifythemedications(byname)thatyouaretaking,dosageandfrequency:
Ifyouhavehadaheadinjurywhereyoulostconsciousnessorwereadmittedtoahospitalforevaluation,pleaseexplainthenatureofyourinjuryandifexperienceanddifficultiesasaresultoftheinjuryinthespacebelow.(memoryloss,lackofconcentration,headaches,visionproblemsetc.)
Describeanyillnessordevelopmentalconditionthatyouexperiencedasachild?
Describeanyseriousinjuriesorbrokenbones:
Identifyanymajorsurgeriesyouhaveexperiencedstartingwiththemostrecent:
Doyouhaveanyspecialdietrestrictionsorrequirements? Yes NoPleaseexplain:
Dateoflasteyeexam: Results: Excellent Good Fair Poor
Areyourequiredtowearprescriptionglasses? Yes No Doyoupresentlyownapair? Yes No
Dateofyourlastdentalexam: Conditionofyourteeth: Excellent Good Fair Poor
Pleasedescribeanyproblemsthatyouareexperiencingwithyourteeth.
Howmanycupsofcaffeinateddrinks(coffee,tea,pop,energydrinks)doyouhaveperday? Cups
Howmanypacksofcigarettestoyousmokeperday? Doyouusechewingtobacco? Yes No
Haveyoueverreceivedmentalhealthtreatmentnotrelatedtodrugoralcoholuse? Yes No
NameofClinic Date:
ReasonforMentalHealthTreatment:
NameofClinic: Date:
ReasonforMentalHealthTreatment:
NameofClinic: Date:
ReasonforMentalHealthTreatment:
NameofClinic: Date:
ReasonforMentalHealthTreatment:
WouldyoubewillingtoauthorizereleaseofinformationfromtheaboveclinicstoTeenChallenge? Yes No
ForWomenOnly
Agewhenyoufirstexperiencedaperiod: Daysbetween: Lengthofperiod:
Doyouhavenormalmenstrualcycles? Yes NoIf no, pleaseexplaininthespacebelow.
Doyouexperiencea Heavy Medium Lightflow?
Doyouexperienceanybleedingbetweenperiods? Yes NoPleaseexplaininthespacebelow.
Whenwasyourlastpelvicexam? Date: Werethereanyadversefindings? Yes No
Pleaseexplain:
Doyouthinkyouarepregnantatthistime? Yes No
NumberoffulltermPregnancies:
Haveyouexperiencedanymiscarriages? Yes No Haveyouhadanyabortions? Yes No
Pleaseexplainanycomplications.
Haveyouexperiencedmenopause? Yes No
Pleaseexplainanycomplicationsbelow.
Haveyouexperiencedaneatingdisordersuchasanorexiaorbulimia? Yes No
Pleasedescribeindetailincludinganytreatmentyouhavereceivedforthisinthespacebelow.
SubstanceAbuseandTreatmentHistory
Indicatebelowthealcohol,drugandmedicalprogramsyouhaveattended.
DateAdmittedandDischarged Program/Facility ReasonforLeaving
Pleaseexplaintypesoftreatmentandcounselingreceived.
Pleaseusethechartbelowtodescribeyouruseofalcoholanddrugs.
Whenansweringthequestionof“HowOftenTaken”,useOforOnce,STforSeveralTimes,RforRegularlyandCforcontinuoususage.
ALLDRUGTYPESUSED:(includestreetdrugs,
alcohol,illegalprescriptions,overthecounter&otherdrugs.)
CURRENTLY
USING
PRESCRIBED
BYAPHYSICIAN
AGEWHENFIRSTUSED
AGEWHENLASTUSED
HOWOFTENTAKEN
CHECKUSUALMETHODOF
ADMINISTRATIONYES NO YES NO Oral Smoke Snort IM IV
Alcohol
Amphetamines/speed(UppersBenzedrine,Dexedrine,etc.)
Anti-depressants
Barbiturates/downers
Chew–Tobacco
Cocaine/crank
Codeine
Darvon
Diladud
Hallucinogens(LSD,Acid,Mescaline,etc.)
Heroin
Inhalants(Glue,Paint,Gasoline,etc.)
Marijuana/hashish
Meth
Methadone–non-legal
Opiates(Percodan,Opium,Morphine)
PCP(AngelDust,etc.)
Ritalin
Tobacco–smoking
Tranquilizers
Valium,Librium
Other(specify):
Theundersignedfullyacknowledgesthattheinformationprovidedhereinisaccurateandtruetothebestofhisorherknowledge.Anyfalseorincompleteinformationmaycauseandresultindisqualificationfrom
admittanceordismissalfromtheprogram.
Applicant Date
IF THIS APPLICATIONFORMHASBEENCOMPLETEDORFILLEDOUTBYANYONE, OTHERTHANSTUDENTAPPLICANT, PLEASEPROVIDEFOLLOWING:
Nameofindividualfillingouttheform Date
RelationshiptoApplicant