Physical Details & Conditions
| Birth Date – Age | May 22, 1974 – 52 yo |
| Height – Weight | 5' 7" – 1000 |
| Cooper Test (1.5 mile run) |
Date: Dec 22, 2027 Altitude: 1501 ft Duration: 12:11 min |
| Smoking / Vaping | No |
| Pregnancy | No |
| Regular Physical Activity |
lift 4x week Lift, 3x week row, 1x week yoga, 3x day |
| Hx Significant Injuries (3 yrs) | trench foot |
Health & Physical Exam Form, Student-Supplied Information (2 of 2)
Medications & Medical Conditions
| Condition | Yes/No | Description / Details |
|---|---|---|
| Benzodiazepine Use | No | |
| Medications | Yes |
bupropion, 300mg
Vitamin-C 100mg Sweet Love, 100cc |
| Asthma | Yes |
Medications: albuterol ER/Hospitalizations: Yes |
| Hx Anaphylaxis | Yes | I start screaming "I'm reacting!!" |
| Hx Heat-Related Illness / Dehydration | Yes | HOT HOT HOT |
| Hx Urinary Tract Infections | No | |
| Hx Relevant Reproductive System Concerns | Yes | PCOS |
| Emotional / Psychiatric History | Yes | depression and anxiety |
Allergies
▣
Bee stings
▢
Dairy products
▢
Iodine
▢
Penicillin
▢
Peanuts
▢
Shellfish
▣
Sulfa Drugs
▢
Sulfite food additives
▢
Wheat/gluten
▣
Other: Corn
Health Conditions
▢
Arthritis (to the extent of interfering with rigorous hiking)
▢
Cardiac or Heart Problems
▣
Fainting Spells
▢
Hepatitis
▢
HIV/AIDS
▢
Hypertension
▢
Hypoglycemia/Diabetes
▢
Dehydration or Heat-related Medical Conditions
▣
Obesity (to the extent of interfering with rigorous hiking)
▢
Renal Disease
▢
Seizure Disorder
▢
Ulcers
▢
None of the above