The Wilderness Program
Cancer Survivor Medical History Form
The Wilderness Program at the Cancer Wellness Center provides young adult cancer survivors with a free backpacking trip in some of the most scenic spots in the Midwest. These trips typically last 3-5 days and involve carrying a backpack while hiking. Participants will sleep outdoors in tents and will spend part of the day hiking, preparing meals, cleaning, and enjoying the great outdoors.
The goal of the program is to enhance the overall quality of life of every participant by exposing them to a restorative environment. The trips are also intended for the participants to have fun, and enjoy an escape away from their normal routine. The first priority, however, is to ensure the safety of every participant. Because we will be operating in remote areas with little to no cell phone reception, evacuation to medical facilities may be delayed.
Current medical status and health history of our participants is essential to addressing safety concerns. Even though the trips are led by a licensed clinical psychologist, the purpose of the program is not to address psychological issues or behavioral problems. We ask that participants refrain from using tobacco, alcohol, and other substances while on the trip.
Name of Applicant
First Last
Birthdate HeightWeight
Name of Medical Professional Who Completed This Form
FirstLast
Medical Degree
Hospital/Health Care Facility
Phone Number Email
Applicant’s Cancer History
Diagnosis & StageDate of Initial Diagnosis
Was there a recurrence?
Yes
No
If Yes, please indicate the date and location of last recurrence
Is the applicant currently in remission?
Yes
No
Applicant’s Cancer Treatment History
Did the applicant ever have surgery?
Yes
No
If yes, please list the type and dates of all surgeries.
If yes, is the applicant currently undergoing any treatments or having any complications from surgery?
Did the applicant receive chemotherapy?
Yes
No
If yes, please list date of last chemotherapy.
If yes, what chemotherapy medications did the applicant take?
Is the applicant currently undergoing any treatments for and/or bothered by any complications related to chemotherapy?
Yes
No
If yes, please explain.
Did the applicant receive any radiation therapy?
Yes
No
If yes, please list the date of last radiation treatment?
If yes, where was the radiation therapy received?
Is the applicant currently undergoing any treatments for and/or bothered by any complications related to radiation therapy?
Yes
No
If yes, please explain.
General Medical History
Is the applicant allergic to anything, including medications, bees, and insects?
Yes
No
If yes, please explain
Does the applicant have a smoking history?
Yes
No
If yes, please explain
Please list any abnormalities that the applicant has in his/her current general medical state.
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From your perspective, does the applicant have any physical or emotional conditions that could interfere with her/his ability to participate in the Wilderness Program?
Yes
No
If yes, please explain.
I have reviewed the applicant’s medical information and history (please indicate the appropriate choice below):
I find the applicant to be in adequate condition for travel and participation in the aforementioned activities, except for any physical limitations and restrictions listed above.
I do not recommend the applicant participate at this time.
By signing below, I acknowledge, that I have carefully considered the questions and have provided an accurate assessment of the applicant’s health.
Signature Date
For more information visit:
Or contact Evan Byer, Psy.D. at or 847.562.4979
Fax: 847.509.9596