Health & Physical Exam Form

To be completed by a physician (MD), nurse practitioner (NP), or physician's assistant (PA).

Note to Physician, Nurse Practitioner, or Physician’s Assistant:

Before completing the physical exam, please review pages 1-2 of this Health Form for information provided by BOSS about the course, and the health history information provided by the participant. If a response on the previous pages is negative and might disqualify a participant, please contact us directly with questions or do not approve participation. Call our administrative office with additional questions, 800.335.7404. If necessary, we will put you in contact with our consulting physician.

If the participant has cardiac risk factors such as a known heart condition, high blood pressure, current or prior cardiovascular disease, family history of heart disease, diabetes, etc., and is over the age of 35, a stress test (in addition to the exercise tolerance test below) should be considered.

Participant Information

Height:    Weight:    Frame:    Blood Pressure:    How long have you known this patient?

Does this person appear healthy and fit enough to hike long distances over rugged terrain, endure variable temperatures ranging from hot days to cold nights, endure some caloric deficit during short intentional periods of fasting, and assume the risk of occasional moderate dehydration? Note that our instructors are Wilderness First Aid certified and available at all times to assess student health and address any concerns should they arise.

Date of last tetanus toxoid inoculation shot: (Mandatory within 10 years)

Notes concerning participant's health history or conditions:

BOSS courses travel in remote wilderness areas where access to medical care may be hours away. There may be limited access to food and water at times. Please describe all medications being taken by this patient including over-the- counter drugs and if the drugs may be taken under these conditions. Participants must be able to administer prescription medications on their own and without additional supervision.

Please list any prescription drugs whose use will be discontinued during the BOSS course and why:

Exercise Tolerance Test (required)

Please have the person do any activity that gets their heart rate elevated and check their pulse.

Resting pulse:    After 1 minute vigrous exercise:    After 2 minutes rest:    Summary of findings:

I have interviewed and examined the patient named above and understand they are planning to attend a BOSS course. I have reviewed and confirmed all health and medical information supplied by the applicant in this 3-page form. I have read and understood the nature of the activities on the course including that the applicant will be travelling in remote areas where medical care may be hours away.

Health & Physical Exam Form, Student-Supplied Information (1 of 2)

IMPORTANT: BOSS requires the following Health and Physical (xamination Packet to be fully completed by the participant and a Physician (MD), Nurse Practitioner (NP), or Physician’s Assistant (PA).

A BOSS course is a rigorous experience in the remote wilderness of southern Utah. Students must be both physically and emotionally fit enough to hike long distances over rugged terrain, endure variable temperatures ranging from hot days to cold nights, and experience some caloric deficit on days when food is hard to find or during intentional periods of fasting. Water in the desert environment can be less abundant than students are used to, and students must be physically fit enough to assume the risk of occasional moderate dehydration.

We work hard to mitigate all unnecessary risks for our students. Our instructors are extensively trained and experienced in leading BOSS courses and all instructors maintain a Wilderness EMT or Wilderness First Responder certification. Instructors carry medical equipment on all courses and are prepared to respond to medical emergencies if they arise.

A BOSS course is NOT the time or place to rehabilitate serious physical, emotional conditions, or detoxification from substances. The staff is not trained in mental health counseling or in managing medical complications due to prior injury or medication.

Please call the BOSS Offce with any questions or concerns: 800.335.7404.

Participant Supplied Information, to be Reviewed by an MD/NP/PA: