Medical History Form - En Route Consulting

Name:*

Date of Birth (00/00/0000)

Sex Assigned at Birth:

Male
Female

Gender Identity:

Man
Woman
Non-Binary
Other

Do you identify as transgender?

Yes
No
Prefer not to answer

What racial or ethnic group/s do you most closely identify with? You can select more than one option by holding down the ctr button..

Medical Conditions: Physical

Having some background on your health is important to matching you with appropriate programs. Please be as transparent as possible and understand this is a judgement-free zone. Have you ever had or have you now:

If you answered yes to any of the above, please describe further. (When you had issue and if it still affects you)

Knowing your medical history is important to both matching you with an appropriate programs as well as making sure you are prepared for situations that could come up in the field.

Medical Conditions: Mental Health/Socio-Emotional

Having some background on your health is important to matching you with appropriate programs. Please be as transparent as possible and understand this is a judgement-free zone. Have you ever had or have you now:

If you answered yes to any of the above, please describe further, including any challenges you are currently facing:

Are there any activities you cannot participate in due to your health conditions?

(e.g. If you cannot SCUBA due to recurrent ear infections)

How physically active to you consider yourself?

Exercise is defined here as engaging in an activity that raises your heart rate for 30 minutes or more at a time. Things like walking the dog, after school sports, hiking, mowing lawns and shoveling snow all count!

Very Active (I exercise 5+ times/week)
Active (I exercise 3-5 times/week)
Somewhat Active (I exercise 1-3 times/week)
I don't consider myself active

Please list any prescription medications you are taking:

Is there anything else to know about your health?

Are you eligible to receive a Pell Grant to attend college?*

NOTE: Federal Pell Grants usually are awarded only to undergraduate students who display exceptional financial need and have not earned a bachelor's, graduate, or professional degree. Pell Grant eligibility is determined through the FAFSA application. Each family's financial situation is different, and there's no one income cutoff to determine eligibility. However, most Pell Grants are awarded to students whose families make less than $30,000 annually. Some are awarded to students whose families make $30,000-$60,000 annually. It's possible but rare for students to be awarded the grant if their families make more than $60,000 annually.

Yes
No
Not sure

Student Medical History