Welcome Questionnaire

Name

First Last

Civi Event

We have a few questions we like to ask to get to know you and your child better. Answering yes to any of these questions will not necessarily preclude your child from attending DHE -it assists us in understanding any health issues or concerns, and is our way of supporting each of our participants in having a successful expedition. Please understand that this information is shared only with DHE staff, or others assisting us with our program screening. Otherwise, the information is treated as confidential. This is an initial questionnaire only. Most of these questions are asked on the medical form that we will send out later. We ask them now so that if you answer “yes” to any of these, we can send a follow up form.

How is the applicant's health?

Excellent
Good
Fair

If not excellent: Any particular reason that you believe your child’s health to be good/fair? Please explain.

Does your child have any chronic conditions or illnesses?

Yes
No

If yes: Please explain in detail the condition or illness.

Is your child active?

Yes
No

If no: Explain that DHE can by physically challenging.

Include any notes about physical activity from the ensuing conversation.

Is your child athletic?

Yes
No

Include any notes about athleticism from the ensuing conversation.

...in particular: which activities/sports they participate in.

Does your child have asthma?

Yes
No

If yes: How is asthma controlled? (with an inhaler/medication?)

What triggers an attack? Last episode? Ever been hospitalized?

Are there any cardiovascular issues?

Yes
No

If yes: Please describe history, risk factors, and triggers.

Does your child have any orthopedic injuries or conditions? (Broken bones, sprains, weaknesses, scoliosis, or flat feet?)

Yes
No

If yes: Type of injury? When did it occur? What is the most rigorous activity s/he has participated in since the injury? Results?

Has your child had any head injuries, concussions or severe headaches (Migraines)?

Yes
No

If yes-concussion: How long did s/he lose consciousness?

If yes-Headache/migraine: Frequency? Are they debilitating?

Any neurological conditions?

Yes
No

If yes: History of seizures? Medications for this? Dizziness/vertigo fainting episodes?

Describe frequency, date of last episode, and severity.

Has your child had any surgeries in the past year?

Yes
No

If yes: describe the type of surgery. Recovery? S/he participated in activities since? Results?

Does your child have any allergies (food, bees, environmental)?

Yes
No

If yes food: medically related intolerance to food? Dietary preferences? Need an epi pen? Does s/he know how to use it? Can s/he be around that food?

“There are specific questions on the health form regarding nut allergies -please be sure to answer them thoroughly.”

If yes bees: if stung, does it result in hives? Swelling of the face/lips? Difficulty breathing? Need an epi pen? Does s/he know how to use it?

If yes environmental: Specific triggers/time of year (season)? Reaction? Debilitating? Need medication?

“There are specific questions on the health form regarding nut allergies -please be sure to answer them thoroughly.”

Does your child have any learning differences?

Yes
No

Is your child on the Autism Spectrum, (this includes Asperger’s Syndrome and PDD)?

Is your child in counseling?

Yes
No

if yes: How long has your child been in counseling? What event triggered the need to see a specialist? How often does your child go to counseling? Will your child be ‘okay’ away from counselor during their time at DHE (3 weeks) Is you child on any medication?

History of an eating disorder or self abuse?

Yes
No

History of any substance abuse or tobacco use?

Yes
No

If yes: is this currently an issue? How long since issue has been resolved? Triggers? Stable enough to participate in a 3 week wilderness expedition?

History of depression, anxiety, OCD, ADHD?

Yes
No

If yes: Medications for this?

Has participant had any behavioral issues at school in the last two years or been expelled from a school or summer program?

Yes
No

If yes: Please explain:

Are there any other issues/conditions/necessary accommodations that we should know that might impact your child’s experience here at Deer Hill?

Yes
No

If yes: Please explain:

How does your child feel about coming to DHE?

Excited
Nervous
Mixed

Notes on Applicant's feelings about coming to DHE

Do you, or your child, have any other questions about Deer Hill in general or your specific program?

Include any notes here.

Notes

DHE staff: If the participant is foreign, ask about their English proficiency in terms of understanding and following directions, communicating and being a safe member of the group. Parent Reminder: Your child will need a complete physical exam, an immunization record and a current tetanus or tetanus waiver. Please be sure to list all medications on the medical form with reason for taking it and any side effects. Please send the following forms: • Mental Health •Asperger’s/Autism • Asthma • Allergies

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