Cancer Survivor Medical Form

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BACKGROUND HISTORY FOR THE MEDICAL PROFESSIONAL

Who Should Complete this Form?

This form should be completed by a medical professional who can attest to the applicant’s medical history and specifically their cancer care/treatment history. This should NOT be completed by the applicant.

What is Your Role in Completing this Form?

True North Treks is NOT requesting medical clearance from you, so please do not communicate this to the applicant as it can cause confusion. Medical clearance and ultimate approval for our treks is provided by TNT’s Medical Director upon review of the provided information. If we have any question on the applicant’s capacity to successfully complete the course, we well call him or her to discuss it, and if needed, contact you for additional clarification.

What is True North Treks?

True North Treks (TNT) is a 501(c)3 nonprofit organization that since 2008 has supported adolescents, young adults, and caregivers through free backpacking, canoeing, and nature retreat-style experiences in backcountry wilderness destinations or at a nature-based retreat center in Upper Michigan. Treks usually last from 4 to 6 nights in duration and are led by professional guides who are trained as wilderness first responders, have established contacts with local medical personnel, and utilize satellite communication devices for safety and medical evacuation purposes.

TNT is NOT a correctional, therapeutic, behavioral or rehabilitation program and is not a place to quit smoking, drinking or drugs or to work through severe behavioral or psychological problems. We ask that participants refrain from tobacco use, substance use, or unsafe behaviors or they will risk expulsion from the trek at their own expense. Prior physical conditioning and an enthusiastic mental attitude are prerequisites. Each participant is expected to take good care of him or herself.

What are Potential Risks and Demands on a Trek?

TNT courses are usually offered during summer, fall, and winter months (winter at our retreat center); however, participants could still be faced with challenging weather conditions including storms, high winds, varying temperatures, intense sunlight and insects. Physical demands on the applicant may include carrying a backpack weighing upwards of 40 pounds over uneven terrain, ascending and descending steep surfaces, and/or canoeing in rivers with strong currents. Elevations for some courses range from sea level to 10,000 feet. On backcountry treks, participants sleep outdoors in tents and protected shelters and will spend most days hiking, backpacking and/or canoeing. They set up their own camp and prepare their own meals. Because some TNT participants may be immuno-compromised, appropriate water purification methods (e.g., boiling, filters) are used to prevent cryptosporidium.

The current medical status and health history of our applicants can add to the potential for adverse health reactions. Because TNT operates in remote areas, evacuation to modern medical facilities could potentially be delayed depending on the circumstances. Because participant safety is our first priority, everything will be done to assure the safety, health and well-being of TNT participants.

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM ON BEHALF OF THE APPLICANT SO THEY MAY EXPERIENCE A UNIQUE AND POWERFUL OPPORTUNITY TO CONNECT WITH NATURE, CONNECT WITH PEERS, AND CONNECT WITH THEMSELVES!

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Cancer Survivor Applicant Information

First Name *

Last Name *

Birth Date *

Medical Provider Information

First Name *

Last Name *

Profession/Discipline *

Phone *

Email *

Applicant's Cancer History

Initial date of diagnosis *

Primary site or type of the applicant's cancer *

If other site or type, please describe:

Did the cancer spread to other parts of the applicant's body? *

Yes

If yes, please explain the locations to which it spread.

Did the applicant experience a cancer recurrence? *

Yes

If yes, please write the date and location of the most recent recurrence.

Is the applicant currently in remission? *

Yes

Applicant's Cancer Treatment History

Surgical Treatment

Did the applicant have surgical treatments in the past? *

Yes

If yes, please write the date and type of past surgeries.

Is the applicant currently scheduling a surgical treatment? *

Yes

If yes, please write the date and type of surgery as well as any complications.

Chemotherapy Treatment

Did the applicant receive chemotherapy treatments in the past? *

Yes

If yes, please list the dates and medications of past chemotherapy treatments. Please include the last date of chemotherapy.

Is the applicant currently receiving chemotherapy treatment? *

Yes

Please write the date(s) and medication(s) of the current chemotherapy.

If yes, does this therapy regimen have a planned completion date? or maintenance phase? Please describe

Is the applicant currently receiving any anti-cancer therapies? *

Yes

If yes, does this therapy have a planned completion date? Or maintenance phase? Please describe

If the applicant is receiving maintenance therapy of any nature, what date did the therapy begin?

Has the applicant experienced any complications receiving this maintenance therapy? If so, please describe.

**Please note, if the applicant is on maintenance therapy, we may request an evaluation with laboratory assessment within 4 weeks of the trek being applied for.

Is the applicant currently taking any myelosuppressive preventative therapy? *

Yes

If yes, please describe this therapy

Is the applicant currently or have they ever been bothered by or experienced any complications related to chemotherapy/anti-cancer therapies? *

Yes

If yes, please describe the chemotherapy-related complications.

Radiation Therapy

Did the applicant receive radiation therapy in the past? *

Yes

If yes, please write the date(s) and location(s) of the past radiation therapy.

Is the applicant currently receiving or recovering from radiation therapy? *

Yes

If yes, please write the date(s) and location(s) of the current radiation therapy.

Is the applicant currently or have they ever been bothered by or experienced any complications related to radiation therapy? *

Yes

If yes, please describe the radiation-related complications.

Stem Cell & Bone Marrow Transplant Therapy

Did the applicant receive stem cell therapy or bone marrow transplant in the past? *

Yes

If yes, please write the date(s) and type(s) of past stem cell or bone marrow treatments.

Is the applicant currently undergoing any stem cell therapy or bone marrow transplants? *

Yes

If yes, please write the date(s) and type(s) of current stem cell or bone marrow treatments.

Is the applicant currently or have they ever been bothered by or experienced any complications related to stem cell therapy or bone marrow transplants? *

Yes

If yes, please describe the stem cell or bone marrow treatment-related complications.

Labs

Date of last blood lab evaluation *

Most recent absolute neutrophil count >0.5? *

Yes

Most recent hemoglobin > 8.0? *

Yes

Most recent platelet count > 50? *

Yes

General Medical History

Please describe all known medical conditions indicated above as appropriate (e.g. currently controlled by medications, potential triggers or complications, frequency and date of most-recent episode). This is especially important for seizure and bleeding-related conditions.

Does the applicant have a history of smoking? *

Yes

If yes, please describe number of years and packs per day as well as, if applicable, quit date.

Does the applicant have a history of substance abuse? *

Yes

If yes, please describe (substance, duration, recovery date, etc.).

Does the applicant have any physical, cognitive, sensory, or emotional conditions that could interfere with his/her ability to participate in this program? *

Yes

If yes, please describe the condition and your concerns.

Allergies and Medications

Is the applicant allergic to medications, foods, insects, or something else of which we should be aware? *

Yes

If yes, please list allergies, describe reactions, and let us know whether an epi-pen is carried by the applicant.

Current prescription and non-prescription medications: dose, frequency, method of administration, and reason for use. *

Physical Exam

Height *

Weight *

Blood Pressure *

Heart Rate *

Oxygen Saturation *

Appearance *

Normal

Abnormal

Ears, Eyes, Nose & Throat *

Normal

Abnormal

Respiratory *

Normal

Abnormal

Cardiac *

Normal

Abnormal

Abdomen *

Normal

Abnormal

Lymphatic *

Normal

Abnormal

Genitourinary *

Normal

Abnormal

Musculoskeletal *

Normal

Abnormal

If abnormal for any of the above, please describe.

Pregnant *

Yes

N/A

Thank you for completing this form. We ask participants to alert us should their medical status change in any way prior to their trek so we have an opportunity to reevaluate their situation and eligibility.

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Date Medical Form Submitted *

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