STATEMENT OF PSYCHOLOGICAL AND HEALTH CONDITION
(All information provided on this form is kept confidential.)
NAME____________________________________________
1- Please list any physical disabilities, allergies, conditions, past injuries or any limitations that could limit your participation on the journey: Include medications that you have an allergic reaction to.
2- What medications are you taking or will you take during the journey? Please list for what conditions these are being taken. Please list any precautions and side effects.
3- Have you been diagnosed with depression, schizophrenia, bi-polar disorder, epilepsy or any other psychological conditions? Please explain the circumstances.
4- Do you have a history of sexual or physical abuse? Do you have a history of substance abuse? Do you have a history of suicidal tendencies or a suicide attempt?
Please initial after each item and then sign below:
5- I declare this statement is correct to the best of my knowledge. I hereby grant permission to the medical personnel, selected by the journey guides, to review my personal records or to contact the appropriate physician, psychiatrist, health professional or psychologist to obtain additional information on the conditions noted.
6- I hereby grant permission to the medical personnel, selected by the journey guides to order x-rays, routine tests and treatment for me in the event the emergency contact cannot be reached.
7- I hereby grant permission to the physician selected by Life by Intent LLC. and representative to hospitalize, secure proper treatment for, and order injections and/or anesthesia for, and/or surgery for me in the case of emergency if the emergency contact can not be reached..
8- I agree to adhere to the decision by Life by Intent LLC. representatives regarding the suitability of my participation in the excursion.
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Participant's Signature and Date