Forklift F 2 License
Resume:
Please complete ALL sections and return to:
adgkvr@r.postjobfree.com
PO Box 25274, Wellington 6146
MEDICAL FORM Fax: +64 4 472 8059
SECTION 1:
PARTICIPANT DETAILS
Completed by participant
FULL NAME : Lizwi Mbatha
EMAIL : adgkvr@r.postjobfree.com
DATE OF BIRTH (DD/MM/YY) AGE : 98 - 08 - 19
IMPORTANT INFORMATION
Doctor and participant must read the following
before completing the medical form:
About Outward Bound
Courses vary in duration from 3-21 days. Designed to be both physically and mentally challenging, activities can include running, swimming, rock climbing, solo, kayaking, sailing and tramping in all weather conditions.
Acceptance
This medical form must be completed by a medical doctor. It will then be reviewed by an Outward Bound Medical Screener/Nurse for final acceptance and confirmation of enrolment. Full disclosure of medical history is necessary to ensure the participant’s and others’ safety. Medical conditions may not necessarily exclude a participant, unless indicated, as long as the condition can be appropriately managed. Medical form validity
This medical form is valid for 90 days from the date it is completed by a doctor and must be valid until the course start date. (If you are between the ages of 16-18 this form is valid for 180 days, unless told otherwise).
Please note, both doctor AND participant MUST complete the signature section of the final page of this form to be considered. Further information
Contact Outward Bound on 080*-***-***.
FITNESS
Can you comfortably run 3km in under 25 minutes and complete a full day’s activity? YES
Excludes some adapted and custom design
programmes that have their own fitness
requirements.
N/A Yes No
WATER CONFIDENCE
SMOKING
Are you confident in water and comfortable putting your head underwater? YES
Are you prepared to go
smokefree at Outward Bound?YES
Can you swim 20 metres? NO
Do you smoke? YES
Yes
Yes
Yes
Yes
No
No
No
No
Page 1 of 5
If yes, how many per day?
HEIGHT (CM)
RESTING
HEART RATE
WEIGHT (KG)
BLOOD
PRESSURE
OFFICE USE ONLY
COURSE CODE
MOBILE PH
HOME PH WORK PH
GENDER
SECTION 2:
MEDICAL HISTORY
Completed by doctor
Page 2 of 5
4. Epilepsy - must be seizure
free for past 5 years (12
months for some adapted
courses)
If you answered ‘yes’ to questions 4-20, provide details in the space below. Please also attach any specialist letters. 5. Diabetes - control of
HbA1c (53-64 mmol is
required)
6. Allergies (food, stings,
medicine)
7. Traumatic experiences
or death of family/friend
in past year
8. High blood pressure
9. Fainting attacks,
blackouts
10. Migraine
11. Hepatitis, HIV or AIDS
related condition
12. Learning difficulties
14. Head injury, concussion,
unconsciousness
15. Current medication
16. Heart condition
17. Backache, spinal injury,
disc trouble
18. Knee, ankle or joint
injury
No Yes
CURRENT
MEDICATION DOSAGE
DATE
COMMENCED
Include HbA1c from past 3 months
If yes include severity and last reaction
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
PARTICIPANT NAME
19. Other serious illness,
injury, operation or
condition
20. Currently pregnant - if
YES participant cannot
attend
Yes
Yes
No
No N/A
2. Behavioural issues
(ADHD)
3. Asthma
If yes, complete section 5
If yes, complete section 4
Yes
Yes
No
No
If yes, complete section 5
1. Mental health
(anxiety, depression, bi-polar,
schizophrenia, eating disorder,
alcohol/drug treatment or
counselling, suicidal thoughts/
attempts, self-harming behaviours)
No Yes
If extra space is required please attach
extra sheet of paper to the back of form
SECTION 2 (CONT.)
Completed by doctor
Does the participant have, or have they ever had,
any of the following:
13. Disability (intellectual,
physical) No Yes
Outward Bound does not require advanced
screening tests (e.g. spirometry, audiometry,
ECGs) unless clinically indicated
Cardiovascular system
Current mental status
Central nervous system
Hearing
Ears
Abdomen
Locomotor system
Respiratory system
Vision
DESCRIBE ANY ABNORMAL FINDINGS:
SECTION 3:
MEDICAL EXAMINATION
Completed by doctor
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Abnormal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
SECTION 4:
ASTHMA INFORMATION
Completed by doctor if answered YES to
question 3
Outward Bound participants will be exposed to a wide range of asthma triggers including vigorous exercise, cold weather, damp weather and allergens. The participant’s asthma must be well-controlled, with a current asthma action plan, to ensure their safety and full participation. Medication Dosage
Date
commenced
Date
last used
YEAR ASTHMA
DIAGNOSED
DATE OF LAST HOSPITALISATION OR
EMERGENCY TREATMENT
PEAK FLOW READINGS
ASTHMA MEDICATION
TRIGGERS
FREQUENCY OF
EXACERBATIONS
Best peak
flow
Expected
peak flow
Current
peak flow
EMERGENCY TREATMENT REQUIRED IN
LAST 2 YEARS?
No Yes If yes, state how many times
PARTICIPANT NAME
Page 3 of 5
WHAT IS THE CURRENT STATE?
DETAILS OF THE HEALTH PROFESSIONAL
COMPLETING SECTION 5
HOW WAS THE CONDITION TREATED?
FULL NAME
OCCUPATION
TELEPHONE EMAIL
Tick here if same as the doctor who is
completing the rest of this form
SECTION 5: MENTAL
HEALTH / BEHAVIOURAL
INFORMATION
Completed if answered YES to questions 1 or 2
This section must be completed by the
health professional who has worked with the
participant e.g. counsellor, psychiatrist, doctor. Outward Bound is mentally demanding - participants will get outside their comfort zone and push their limits. We require full disclosure of any mental health or behavioural issues to ensure the participant’s
and others’ safety. Our aim is to ensure participants are mentally fit so they are able to complete their Outward Bound course in full. Note that Outward
Bound is unable to provide any counselling, treatment or support for mental health or behavioural issues. WHAT IS/WAS THE CONDITION/ DIAGNOSIS?
WHAT TRIGGERED THE CONDITION?
WHAT WERE THE SYMPTOMS?
WHEN WERE THE LAST SYMPTOMS
(INCLUDING DATES)?
HAS THE PARTICIPANT EVER BEEN SUICIDAL,
ATTEMPTED SUICIDE OR SELF-HARMED?
No Yes If yes, provide details including
dates at the top of the next
column
HAS THE PARTICIPANT DISPLAYED
AGGRESSIVE OR VIOLENT BEHAVIOUR?
DETAILS OF SELF-HARM OR SUICIDE ATTEMPT
No Yes If yes, provide details, including dates
Medication Dosage
Date
commenced
Date
last used
PARTICIPANT NAME
Page 4 of 5
SECTION 6:
DOCTOR’S DETAILS
Completed and signed by doctor
DOCTOR’S NAME
MEDICAL CENTRE
TOWN/CITY
EMAIL TELEPHONE
DOCTOR’S STAMP
ARE YOU THE PARTICIPANT’S REGULAR
DOCTOR? No Yes
TODAY’S DATE
TODAY’S DATE
DOCTOR’S SIGNATURE
DOCTOR’S SIGNATURE
/
/
/
/
APPROVAL
Signed by doctor
As a Registered Medical Practitioner: I have read the important information on the front of this medical form. I confirm that all required sections of this medical form are completed in full. I certify that the health and fitness of the participant is:
SATISFACTORY:
PARTICIPANT SHOULD BE ACCEPTED
UNSATISFACTORY:
PARTICIPANT SHOULD NOT BE ACCEPTED
PARTICIPANT DECLARATION
• I declare that the information given in this form is true and complete to the best of my knowledge.
• I understand that if:
a) I have not disclosed all previous medical conditions or injuries, or
b) My medical condition changes or I receive an
injury after signing this form and do not disclose this to Outward Bound before the course, and these
conditions or injuries limit or exclude me from the course, I will not be entitled to a refund.
• The safety and wellbeing of participants on an Outward Bound course is the first concern of Outward Bound. However, I understand that all participants take part at their own risk and must accept personal liability for any injury.
• I authorise Outward Bound to contact the Doctor
who signed this form to obtain further information that may be required.
• I acknowledge that, in accordance with the provisions of the Privacy Act 1993, the following information has been brought to my attention:
a) This form collects personal information about me. b) The information is collected to evaluate my
suitability to attend an Outward Bound course.
c) The intended recipients of this information are those staff directly involved with my attendance.
Outward Bound staff may share relevant information with other health professionals who may be required to be involved in my health care.
d) The Health Information Privacy Code 1994 under
Rules 6 and 7, and the Privacy Act 1993, entitles
me to have access to, and request a correction of, the information. Where correction is not made, a
statement of request for correction will be attached to my records.
e) The information is being collected and held by
Outward Bound.
PARTICIPANT NAME
PARTICIPANT SIGNATURE
TODAY’S DATE
/ /
PARTICIPANT NAME
Page 5 of 5
SIGNATURE
Signed by participant
Please ensure both the doctor AND participant signatures have been completed before submitting this form
Please select one and sign below
Contact this candidate