Internet Addiction Recovery Program APPLICATION ... - HEAL
Internet Addiction Recovery Program APPLICATION ... - HEAL Internet Addiction Recovery Program APPLICATION ... - HEAL
Internet Addiction Recovery Program IMMUNIZATION RECORD LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER SECTION A ‐ REQUIRED IMMUNIZATIONS mo./day/year mo./day/year mo./day/year mo./day/year • DTP or Td (#1) (#2) (#3) (#4) • Td booster • Polio • MMR (after first birthday) • MR (after first birthday) • Measles (after first birthday) **Disease Date ****Titer Date & Result • Mumps • Rubella ***(Disease Date NOT Accepted) ***(Disease Date NOT Accepted) ****Titer Date & Result ****Titer Date & Result SECTION B ‐ RECOMMENDED IMMUNIZATIONS The following immunizations are recommended for all participants. Meningococcal Received the meningococcal vaccine No Yes If Yes, please indicate date(s) vaccine was received (mo./day/year) • Hepatitis B series only month/day/year month/day/year month/day/year ****Titer Date & Result • Hepatitis A/B combination series • Varicella (chicken pox) series of two doses or immunity by positive blood titer • Tuberculin (PPD) Test Date read (within 12 months) mm in duration Chest x‐ray, if positive PPD Date Results Treatment if applicable Date SECTION C ‐ OPTIONAL IMMUNIZATIONS • Haemophilus influenzae type b • Pneumococcal • Hepatitis A series only • Other Disease Date month/day/year month/day/year month/day/year ****Titer Date & Result Signature of Physician/Physician Assistant/Nurse Practitioner Date Print Name of Physician/Physician Assistant/Nurse Practitioner Area Code/Phone Number Page | 14 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
Internet Addiction Recovery Program PHYSICAL EXAMINATION LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER TO THE PHYSICIAN: The program for which this individual is applying may include rigorous physical activity in a wilderness setting. This medical examination form is designed to ensure that participants can safely engage in a program’s activities. Any person with normal physical and mental capacity can be expected to complete our programs successfully. Please review the participant’s medical history and evaluate whether this individual has any conditions that might preclude a successful experience on a rigorous backcountry expedition. This exam must happen within one year of the participant’s program start date. The FOLLOWING LAB WORK is required by the reSTART INTERNET ADDICTION RECOVERY PROGRAM in addition to the physical exam. Please fax results to (425) 222‐7189. • Urine Drug Analysis (UDAs) • Urine test for possible infection • (Females Only) Pregnancy Test with test results indicating positive or negative findings • Comprehensive Metabolic Panel • Complete Blood Count Age:____________ Pulse:____________ Height:____________ Blood Pressure:____________ Body Fat % Weight:____________ Visual Acuity: Left 20/_______ HCT: Right 20/_______ EST VO2 Max: Audiometry: Optional Normal 1. Head 2. Eyes (pupils), ENT 3. Teeth 4. Chest 5. Lungs 6. Heart 7. Abdomen 8. Genitalia 9. Neurologic 10. Skin 11. Physical Maturity 12. Spine, Back 13. Shoulders, Upper extremities 14. Lower extremities Abnormal Page | 15 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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<strong>Internet</strong> <strong>Addiction</strong> <strong>Recovery</strong> <strong>Program</strong><br />
PHYSICAL EXAMINATION<br />
LAST NAME (print) FIRST NAME MIDDLE/MAIDEN NAME PERSONAL ID#(PID) *SOCIAL SECURITY NUMBER<br />
TO THE PHYSICIAN:<br />
The program for which this individual is applying may include rigorous physical activity in a wilderness setting. This medical<br />
examination form is designed to ensure that participants can safely engage in a program’s activities. Any person with normal<br />
physical and mental capacity can be expected to complete our programs successfully. Please review the participant’s medical history<br />
and evaluate whether this individual has any conditions that might preclude a successful experience on a rigorous backcountry<br />
expedition. This exam must happen within one year of the participant’s program start date.<br />
The FOLLOWING LAB WORK is required by the reSTART INTERNET ADDICTION RECOVERY PROGRAM in addition to the physical<br />
exam. Please fax results to (425) 222‐7189.<br />
• Urine Drug Analysis (UDAs)<br />
• Urine test for possible infection<br />
• (Females Only) Pregnancy Test with test results indicating positive or negative findings<br />
• Comprehensive Metabolic Panel<br />
• Complete Blood Count<br />
Age:____________ Pulse:____________<br />
Height:____________ Blood Pressure:____________ Body Fat %<br />
Weight:____________ Visual Acuity: Left 20/_______<br />
HCT:<br />
Right 20/_______<br />
EST VO2 Max:<br />
Audiometry:<br />
Optional<br />
Normal<br />
1. Head<br />
2. Eyes (pupils), ENT<br />
3. Teeth<br />
4. Chest<br />
5. Lungs<br />
6. Heart<br />
7. Abdomen<br />
8. Genitalia<br />
9. Neurologic<br />
10. Skin<br />
11. Physical Maturity<br />
12. Spine, Back<br />
13. Shoulders, Upper extremities<br />
14. Lower extremities<br />
Abnormal<br />
Page | 15<br />
reSTART <strong>Internet</strong> <strong>Addiction</strong> <strong>Recovery</strong> <strong>Program</strong> | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189<br />
restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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