Intake and Medical History Form

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Intake and Medical History Form

60 Plato Blvd E. Ste 210 Saint Paul, MN 55107 l Phone: (651)-209-9900

Legal first name

Legal last name

Preferred first name

Pronouns (they/them, she/her, he/him, etc.)

What pronouns would you prefer to use at the Corps?

Cell phone

Do you have access to a computer/iPad and internet connectivity?

Program

In situations requiring shared sleeping/restroom space (i.e. orientations, retreats, spike camping), would you prefer to be housed in a "male" or a female" space?

Do you have any dietary restrictions or food allergies/intolerances?

YesNo

If yes, please explain.

T-shirt size (men's sizing)

For everyday shirt sizing.

Glove size

For safety gear

Boot size (input men's sizing; indicate wide/narrow if necessary)

Steel-toe boots are only offered in men's sizing. See a rough chart of converting men's sizing to women's below. Note that men's shoes are slightly wider than women's shoes.

Men's to Women's Shoe Size Conversion Chart

Button-down shirt size (men's sizing)

For fire gear sizing

Pant size (waist measurement x inseam length)

For fire gear sizing

Do you have rain gear?

Rain gear size requested

Do you have a sleeping bag?

Do you have a sleeping pad?

Do you have a tent?

Do you wear prescription glasses or contacts?

YesNo

Do you have a current First Aid/CPR/AED certification?

YesNo

Date of Birth

Mailing Address

Address Line

Mailing City

City

Mailing State

State

Mailing Zip Code

Zip Code

Emergency Contact Information

Contact #1

Name

Relation

Cell phone (must not be the same as yours)

Business/home phone

Contact #2

Name

Relation

Cell phone

Business/home phone

Health Insurance

AmeriCorps members serving in a full-time capacity are required to have health insurance coverage during their term of service. Please indicate your health insurance status below.

I am covered by family/personal insurance.
I want to enroll in the Conservation Corps' insurance plan.

MEDICAL HISTORY: Include ALL previous injuries/conditions, even if they have been treated and resolved. Please be as detailed as possible

Diabetes

YesNo

Insulin Dependent

YesNo

Diabetes Explanation

Seizure Disorder

YesNo

Date of last seizure

Seizure Explanation

Heart Condition

YesNo

Heart Condition Explanation

Pulmonary/Respiratory Disease

YesNo

Pulmonary/Respiratory Disease Explanation

Chronic/Infectious Illness

YesNo

Chronic/Infectious Illness

Hernia

YesNo

Hernia Explanation

Back Injuries/Conditions

YesNo

Back Injuries/Conditions

Head Conditions

YesNo

Head Conditions

Musculoskeletal Injuries/Conditions

YesNo

Musculoskeletal Injuries/Conditions

Bleeding/Blood Disorder

YesNo

Bleeding/Blood Disorder

Vision/Eye Conditions

YesNo

Vision/Eye Conditions

Hearing Conditions

YesNo

Hearing Conditions

Mental Health Condition

YesNo

Mental Health Conditions

Within the past five years, have you experienced or been treated for any conditions NOT disclosed above?

YesNo

Please explain.

Do you have any other conditions or limitations (physical, mental, or emotional) that might impact your ability to perform the essential functions of this job?

YesNo

Please explain.

Asthma and Allergies

Do you have asthma?

YesNo

What triggers your asthma?

What are your symptoms?

What medications do you require?

Have you ever required emergency treatment or hospitalization for your asthma? If yes, when, and what were the circumstances?

When as your last episode?

What best describes your current condition?

Do you have allergies

YesNo

Allergy #1

Describe reaction

Date of last reaction

Severity

Treatment

Do you have additional allergies to report?

YesNo

Allergy #2

Date of last reaction

Describe reaction.

Treatment

Severity

Do you have additional allergies to report?

YesNo

Please explain.

MEDICATION: It is your responsibility to ensure you have adequate medication throughout the duration of your term. Please identify all prescribed and/or over-the-counter medications you are taking.

I have medications to report.

YesNo

Medication #1

Condition Treating

Physical reaction when NOT taken.

Side Effects

Additional medications?

yesNo

Medication #2

Side Effects

Condition Treating

Physical reaction when NOT taken.

Additional medications?

yesNo

Please explain.

Work Capacity Test

Service with the Corps requires certain members to successfully complete an arduous Work Capacity Test (WCT). The arduous level requires to walk 3 miles in 45 minutes while carrying a 45 lb pack over level terrain. Upon successful completion of the WCT, members will be eligible for service. Members unfit or unable to successfully complete the pack test may be released from service.

Below is the Health Screen Questionnaire that is required before taking the pack test. A "Yes" answer to any one or more questions requires documentation from your personal physician that you are fit to participate in this activity, but does not automatically preclude you from taking the test. If a "Yes" is indicated, you will be contacted by a Program Manager to discuss the next steps.

During the past 12 months have you at any time (during physical or while resting) experienced pain, discomfort or pressure in your chest?

YesNo

During the past 12 months have you experienced difficulty breathing or shortness of breath, dizziness, fainting or blackout?

YesNo

Do you have a blood pressure with systolic (top #) greater than 140 or diastolic (bottom #) greater than 90?

YesNo

Have you ever had heart surgery, angioplasty, or a pace maker, valve replacement, or heart transplant?

YesNo

Do you have a resting pulse greater than 100 beats per minute?

YesNo

Do you have arthritis, back trouble, hip/knee/joint/pain, or any other bone or joint condition that could be aggravated or made worse by the Work Capacity Test?

YesNo

Do you have personal experience or doctor's advice of any other medical reason that would prohibit you from taking the Work Capacity Test?

YesNo

Has your personal physician recommended against taking the Work Capacity Test because of asthma, diabetes, epilepsy or cholesterol or a hernia?

YesNo

Accommodations

Designated personnel must be made aware of any disability in order to provide reasonable accommodation. It is up to you to determine how much and to whom information about your disability is disclosed. Keep in mind, however, that efforts to provide reasonable accommodations for you depend on the information you provide. An individual with a disability who does not self-disclose has no protection from discriminatory practices under the Americans with Disabilities Act. If you have a disability, we strongly encourage you to contact your Program Staff so that they can work with you to make as many reasonable accommodations as possible.

I have reviewed and understand the essential functions of the position and believe I can perform these functions effectively.

YesNo

I may require reasonable accommodations in order to effectively perform the essential functions of the position.

YesNo

Certification

I have read the introduction of this Medical Form, and I understand that the program is physically and mentally strenuous. The information provided on the preceding pages is complete and accurate. I realize that failure to disclose such information could result in serious harm to me, and/or fellow participants and I agree to indemnify and hold Conservation Corps Minnesota and Iowa harmless if all relevant information is not disclosed. I also agree to notify the Conservation Corps should there be any change in my health status throughout the term. Information requested on this form is considered to be private and by law you do not have to furnish it. If this information is needed due to a medical emergency while participating in the program this information will become public record.

I have read and understand the above note and willfully provide the information requested.

AgreeDisagree

If you do not agree to the certification or would like to request reasonable accommodations, please submit your form and contact the Program Manager who hired you to discuss your needs and concerns.

Contact Information

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