Fachartikel

Blair Dillard Erb

Determining medical suitability for wilderness ventures©

SUMMARY

Physicians may be called upon to assist in determining medical suitability of prospective participants in wilderness activities. To identify features of an examination, a survey was sent to 215 health professionals, wilderness leaders, organizations, and testing centers. Sixty-six were returned. Sixty were of adequate quality to be scored. Three objectives were targeted: 1) characteristics to be included in an examination, 2) the value of each characteristic as a predictor of success or failure, and 3) the single most important predictor of success or failure. From these a generic examination was developed.

Classifications of the nature of the venture and of characteristics of individuals were established. Wilderness venture classifications include: 1) Extreme performance ventures, e.g., high altitude climbs, 2) High performance ventures, e.g., remote hunting activities, 3) Recreational activities, e.g. trail walking, and 4) Therapeutic activities, e.g., cardiac rehabilitation. Prospective participants were classified as: A) Demonstrated high performance individuals, e.g., Mount Everest climbers, B) Healthy, fit but noncompetitive individuals, C) Healthy “deconditioned” individuals, e.g., apparently healthy but with infrequent exercise, D) Individuals with risk factors, e.g., smokers, E) Individuals who are manifestly ill, e.g., coronary artery disease, diabetes mellitus. From these classifications an Exam Code was developed using letters for personal characteristics and numbers for the venture, e.g., C-1, D-3, etc. Armed with these classifications, a generic examination was designed appropriate for the individual and the venture. There were five categories of component features in the examination: 1) Personal data, 2) Historical Data, 3) Medical features, 4) Physiologic assessment, and 5) Psychological evaluation. Most candidates need only certain components as defined by the Exam Code. The survey of health characteristics revealed that the best predictor of a successful venture was a “history of successful similar ventures” (52%), and the best predictor of failure was “demonstrated psychological or interpersonal problems” (75%). Over half of the most valuable features could be derived from a

thorough personal interview which was considered the most important part of the examination. Keywords: Wilderness Medicine, Wilderness Venture Classification

INTRODUCTION

The spirit of adventure is fueled by an irresistible personal need to explore the world around us. So it is with wilderness ventures! The lure of the mountains, deserts, ice caps, seas, and skies, beckons to their admirers in spite of their physical challenges and environmental hazards. In response there has been an enormous increase in participation in a wide assortment of wilderness activities by individuals with markedly varied personal characteristics, health status and experience. In light of the heterogeneous nature of participants, it is of critical importance to identify individuals who might have difficulty with a specific venture or who might place themselves or others in physical jeopardy. The burden of venture planners is to advise individuals of the demands of an activity and to mesh the participant with an appropriate undertaking. Organizers and leaders also seek to identify individual factors which could make a group compatible, cohesive, successful, and above all, safe. A physician is frequently consulted to help select prospective candidates for a wide range of wilderness ventures. It is the purpose of this paper to develop an approach useful to a physician or designated health professional when asked to advise venture planners and participants in their match of an individual with a specific wilderness venture.

CLASSIFICATION OF WILDERNESS VENTURES

When a physician is called upon to assist in the selection of participants for wilderness ventures, it is helpful to classify both the nature of the venture and the personal physical characteristics of the individual (1-3). The venture may be classified according to the physical and environmental demands it places on the participant. Classification of wilderness ventures includes: •Class 1) Extreme performance ventures (e.g., high altitude mountaineering such as a Mount Everest climb), •Class 2) High performance ventures (e.g., remote hunting activities or jungle trekking), •Class 3) Recreational activities (e.g., Alpine hiking, National Park trail walking), and

•Class 4) Therapeutic activities (for those with manifest illness or disability; e.g., cardiac rehabilitation). Table 1.

Table 1

Classification of Wilderness Venture

1. Extreme PerformanceVenture (e.g., high altitude mountaineering such as a Mount Everest Climb)

2. High Performance Ventures (e.g., remote hunting activities or jungle trekking)

3. Recreational Activities (e.g., Alpine hiking, National Park trail walking)

4. Therapeutic Activities (those with manifest illness or disability, e.g., cardiac rehabilitation)

CLASSIFICATION OF PARTICIPANTS IN WILDERNESS VENTURES

To determine the nature and extent of a medical examination of a prospective participant for a defined class of venture, it helps to classify the individual by physical characteristics, functional capacity and experience. The features thus defined can yield an image of the prospective participant for matching with the demands of the venture. In the arrangement outlined here, there are five classifications of participants, Groups A, B, C, D, and E. The population presenting to the physician may fit a Bell distribution curve (Table 2). •Group A: Demonstrated high performance individual.

Some who approach certain wilderness ventures have already been through a form of natural selection. For example, those who aspire to participate in an expedition to high mountains such as Mount Everest will in all likelihood already have participated in other high mountain activities and will have proven their capacity to function at such extremes. •Group B: Healthy vigorous individuals.

Those who participate in regular exercise and activities may stay in good, but not necessarily high level competitive physical condition, yet do enjoy periodic wilderness adventures. Infrequent wilderness activities may be less than needed to maintain adequate functional status. •Group C: Healthy “deconditioned” individuals.

Of greater concern to the examiner are apparently healthy individuals such as business or professional people who have not recently been involved in vigorous activities and have become “deconditioned” yet still have the desire

to participate in an exciting activity. These individuals may have occult medical conditions or unidentified risk factors. •Group D: Individuals with risk factors.

Some individuals seem healthy but could have risk factors which may warrant a thorough medical examination and assessment. •Group E: Individuals who are manifestly ill.

Outdoor activities, including some cardiac rehabilitation programs, have been used as a form of physical therapy in the treatment of many illnesses. Subjects in this category are unique and require a high degree of medical evaluation and supervision.

Not many prospective candidates are types A (high performance) nor E (manifestly ill). Mount Everest climbers are champions who have unique physical capacity, have conditioned themselves, and have the will to reach their goal.

We have traditionally accepted a figure of 10% of our population as being

Table 2

Classification of Participants in Wilderness Ventures

Group A = demonstrated high-performance individuals

A. High performance Group B = healthy, vigorous individuals

Group C = healthy “deconditioned” individuals

Group D = those with risk factors

Group E = those who are manifestly ill

B. Healthy, vigorous

C. Healthy, deconditioned

D. Risk factors

68%

E. Manifestly ill

2.5%

A 95%

2.5%

B C D E Increasing Medical Responsibility

This classification is usefulwhen matching participants with appropriate activities andhelps determine the features of a medical examination. Medical responsibility and consequently the need for more complete examination increases from the individuals in Group A (high performance) to those inGroup E (manifestly ill).

that group involved in athletics (Type A). A similar number of our population, (Type E), have had or still actively have illnesses which have resulted in significant physical limitations which prevent full participation in activities described here.

There has been a shift toward increasing participation in hazardous high performance activities by healthy “deconditioned” people (Type C). Because of the large number of people and the subtleties of possible hidden health problems, it is these people who cause greatest concern for the physician addressing a prospective adventurer. Addressing and correcting risk factors (Type D) is a matter for the clinician. These classifications of ventures and of prospective participants should help physicians and designated examiners make an appropriate match between participants and ventures.

DETERMINING COMPONENTS OF THE MEDICAL EXAMINATION

A survey of health characteristics useful in predicting success or failure by participants in various types of wilderness ventures was derived from opinions of physicians and wilderness leaders responsible for the health and safety of individuals embarking on wilderness ventures. (2) (See Appendix). Personal health features were sorted into five component categories: 1) personal data, 2) historical data, 3) medical findings, 4) physiological assessment and 5) psychological assessment outlined in Table 3, Categories of Components of the Medical Assessment. (2) Some items from these categories which may be considered for possible inclusion in the medical assessment of a prospective candidate are listed below in abbreviated form and itemized in more detail in Table 4, Components Useful in Physicians’Examination: 1)Personal Data: Psychological and interpersonal problems on previous ventures; history of a recent or remote similar venture; use of drugs, alcohol, steroids or tobacco; age, gender, and occupation; level of education; participation in athletics; whether person volunteered or is a recruit. 2)Historical Data: Past illness; family history; problems with previous venture; successful similar venture; psychological problems; intolerance to altitude; intolerance to cold; accident; barotrauma. 3) Medical Features: Blood Pressure; height; weight; cardiovascular examination; pulmonary examination; musculo-skeletal examination; status of metabolic system. 4) Physiological Assessment: Simulation of planned activity; running endurance; running speed; dynamic strength; agility; GXT (graded exercise

test);V02max; PFT (pulmonary function tests); HVR (hypoxic ventilatory response). 5) Psychological evaluation: There were hidden psychological questions in the survey questionnaire but the skill of the interviewer , honed by the examiners medical experience and outdoor experience is the most important modality in assessing the psychologic status of the prospective participant.

Table 3

Categories of Components of the Medical Examination

1.Personal Data

2.Historical Data

3.Medical Findings

4.Physiological Assessment

5.Psychological Evaluation

(See text for some of the specific items included in the examination)

In the survey questionnaire three basic questions regarding specific health characteristics were asked: a) Would you include the characteristic in an examination of prospective participants in a specific wilderness venture? (See Table 4) b)How valuable is the characteristic as a predictor of success or failure? (See Tables 9 A, B, C, D.) c) What is the single most important predictor of success or failure? (See Tables 5 & 6)

Results of question a) are listed in Table 4, (Components Useful in Physician Examination), as the percentage of health professionals who would include the different characteristics in the examination of the prospective participant. The strong interest for including most of the items listed probably reflects the natural inquisitiveness of health professionals who appreciate complete data.

Table 4

Components Useful in Physicians Examination As Recommended by Respondents

1. Personal Data 2. Historical Data 3. Medical Features 4. Physiological 5. Psychological

Psychological and95%Illness 97% Cardiovascular 92% Simulation of 57% * Characteristic Interpersonal Problem* Activity included in Psychological Recent Similar 93%Problems with * 97% Blood Pressure 88% Running 53% Category Venture Previous Venture Endurance

Drugs?* 92%Successful 95% Pulmonary 87% Dynamic Similar Venture Strength 53%

Similar Venture 87% Intolerance to 95% Altitude Musculoskeletal 87% Agility 48%

Alcohol?* 87%Psychological*93% Weight 87% GXT (Graded 40% Problems Exercise Test)

Tobacco?* 87%Intolerance 92%Metabolic 78% PFT (Pulmonary 37% to cold Function Tests)

Age 85%Accident 85% Height 63% V02 Max 37%

Volunteer 78%Family History62% HVR(Hypoxic 25% Ventilatory Response)

Remote Similar 75% Barotrauma 60% RunningSpeed 13% Venture

Occupation 72%

Use of Steroids* 65% Table 4 summarizes the percentage of60 respondents who would include these selected itemsin a medical examination designed Recruit 63% to determine suitability ofprospective participants inwilderness ventures. Gender 62%

Education 60%

Athletics 42%

The relative value of various examination characteristics, question b), are listed in The Questionnaire Response Summary, Tables 9 A, B, C, D (see appendix). Response to question c) regarding the most important predictors of success or failure, indicates greatest interest by examiners in the value of experience, history of successful or failed previous attempts in a similar venture and psychologic factors as predictors of success or failure (Tables 5, Single Best Predictor of Success and Table 6, Single Best Predictor of Failure).

These features can be determined by personal interview and underscore the additional value of face-to-face contact in contrast to making observations limited to physical findings from an examination. The interview presents an excellent opportunity to review the character, knowledge, intelligence and adaptability of the candidate. This is where the wilderness experience of the examiner is of utmost importance in the assessment process. Some examiners refer to experienced outdoor-hardened subjects and experienced outdoor physicians (health professionals) as “Salty Dogs” and the process of interviewing the prospective participant as “Salty Dog Science.” This interview time also gives the examiner an opportunity to determine the immunization requirements of the venture and the status of the individual’s immunization. The need for physiologic studies such as treadmill testing, simulated similar activity, running speed and dynamic strength, laboratory data and radiographic imaging may vary according to the specific venture and characteristics of the candidate and should be individualized by the examining team.

CONSTRUCTING THE MEDICAL EXAMINATION

Armed with a clear understanding of the aims, goals, and physical requirements of specific ventures, the physician may then undertake an objective evaluation of the prospective participant. Of course it is impractical and even unnecessary to do an extensive and complete physical examination on everybody participating in every outdoor venture. For example, a high performance, fit and asymptomatic mountaineer who is planning an easy afternoon hike in the park does not need an examination. But on the other hand, a late middle aged slightly obese hypertensive person with a history of coronary artery bypass surgery would be statistically at risk trying to climb a high altitude mountain and should have a thorough assessment including an alert interview by a health professional experienced not only in medical evaluation but also in the demands of mountaineering.

The classification tables (Tables 1, 2, 3, 4) serve as a guide to constructing a practical medical assessment consistent with the needs of the venture and the characteristics of the participant. Using Table 7, Construction of the Medical Assessment, as the format, items listed in Table 4, Components Useful in Physician Examination, can be selected for inclusion in the examination called for according to the class of the venture and of the participant.

Table 7

Construction of the Medical Assessment of Prospective Participants in Wilderness Ventures

Classification of Classification of Venture Characteristics of 1. Extreme 2. High 3. Recreational 4. Therapeutic Participants Performance Performance

A. Demonstrated High 2,3,5 Performance

B. Healthy, 2,3,4,5

Vigorous 2,3, 5 2 *

2,3,5 2 2

C. Healthy, 1,2,3,4,5 2,3,4,5 “deconditioned” 2, 3, 4 2,3,4

D. Risk Factors 1,2,3,4,5 1,2,3,4,5 2,3,4,5 2,3,4,5

E. Illness * * 1,2,3,4,5 1,2,3,4,5

Category of Components

1.Personal Data 2.Historical Data 3.Medical Findings 4.Physiological Assessment 5.Psychological Evaluation * Individualized assessment indicated

All categories of characteristics should be considered in the examination of prospective participants, but characteristics listed above with bold, underlined numbers in Table 7 are of prime importance and should be emphasized. Lower case numbers should also be closely considered.

For example, as a prospective participant presents for medical assessment, the examiner determines the nature of the venture and classifies the subject according to the Venture (Table 1). These ventures are given a numerical designation, e.g., 1, 2, 3 or 4. Then the examiner estimates the classification of the participants’functional status using the classification of Participants (Table 2). These participants are given an alphabetical designation, e.g., A, B, C, D, or E. These designations, i.e., the numerical label for the venture and the alphabetic label for the participant, may be used together as an exam code to define the interaction of the person addressing the challenge venture. For example, an indi-

vidual who is apparently healthy but “deconditioned”, a class C participant, who wants to climb Mount Everest, a class 1 venture, would be designated exam code “C-1” (see box, Exam Code). The examiner then proceeds with an examination based on the framework found in Table 7 Construction of the Medical Assessment.

EXAM CODE

An Exam Code, based on the four classes of venture (Table 1) and five classes of individual functional characteristics (Table 2), provides a guide for the features of the medical assessment (Table 3). For example, a venture involving climbing Mount Everest, venture Class A, by a highly conditioned experienced climber, Class 1, would have an Exam Code A-1. From this code, the physician determines from Table 8 the categories of features to be included in the exam (Table 3). A deconditioned well person planning to walk leisurely on Smoky Mountain trails would have an Exam Code C3. The examination features would then be derived from the categories listed in Table 3.

Categories of Components (Table 3), i.e., personal data, historical data, medical findings, physiological and psychological evaluation, are used in the design of an examination consistent with the demands of the venture and the characteristics of the individual as outlined in Table 7, Construction of the Medical Assessment. In Table 7, the X-axis presents the classification of the venture. The Y-axis presents the classification of the individual. The categories of components of the individualized medical examination special to the subject presenting for medical assessment are found at the X-Y intersection found in Table 3. The contents of the examination are identified by the numbers representing each component category found in Table 3, (i.e. personal data, historical data, medical findings, physiologic assessment and psychologic assessment) and found in Table 7 at the intersection matching the venture and the participant and outlined in Table 8. The specific component items for the examination are found in Table 4.

So, in the example given above, the healthy deconditioned person wanting to climb Mount Everest, i.e., a class C-1subject, would ideally have a complete examination with all five categories of components of the complete medical examination. A healthy vigorous individual, on the other hand, who wants to go for a leisurely walk on a developed trail in a park, i.e., a class B-3, if questioned by an experienced health professional, should need no more than an interview.

All categories of characteristics should be considered in the examination of each prospective participant, but some characteristics may be of greater importance in certain circumstances. For example, the high performance individual who wants to take part in recreational activity has very little medical requirement. On the other hand, a subject with demonstrated cardiovascular disease who wants to participate in high level activities would be well advised to have a careful examination, perhaps including physiologic testing such as a graded exercise test as determined by the clinician. Physician judgement is essential in such instances and this scheme is presented simply as a guide.

DISCUSSION

There has been a dramatic increase in the popularity of wilderness activities in the last 20 years. Attendant with this increase is a rise in accidents, injuries and even tragedies. There are frequent reports of inexperienced or physically and emotionally ill-prepared individuals participating in activities which are beyond their limits. Recognition of this problem has brought a flood of admonitions recommending planning before embarking on a wilderness adventure. Published precautions are usually directed only at specific problems, e.g. bear attacks, hypothermia, or adequate food and water, but other medical and environmental problems should be addressed. Included in the concerns of wilderness leaders are the physical, mental and emotional demands of the venture when matched with the capacity of the participant to function safely. During the planning of wilderness ventures, a physician may be called upon to assist in the selection of prospective participants. In an effort to help a physician or other health professional identify individual characteristics which may serve as predictors of success or failure in planned ventures, a questionnaire was designed and sent to health professionals, leaders and certain participants in planned ventures. Emphasis was on identifying these predictors and various components of a medical assessment. The intent was to use the results to develop the content of a medical examination which could serve as a guide for phy-

sicians, other health professionals and venture leaders as a predictor of success or failure in a safe wilderness venture. Although traditional physical components of a medical examination are important and recommended (Table 4), the health characteristics most valued by an experienced outdoor-hardened examiner are derived from the quality of the physician/participant interview. An experienced outdoor physician can recognize during the interview the judgment and stability of a prospective participant. This helps in advising and designing a safe and satisfying wilderness venture commensurate with the characteristics of the participant. We recognize that an elite cadre of experienced leaders can select participants in high performance activities or can recognize individuals at risk very effectively by empiric techniques. In an effort to determine the productive features of techniques used by those examiners experienced in the wilderness, we undertook this review by observing the experiences of these “Salty Dogs.” The interface between examiners experienced in the wilderness and participants who may, or may not, be experienced has been called “Salty Dog Science.” At the conclusion of the Appendix, a simple and traditional Wilderness Medical Assessment form developed from the structure and findings of this survey is presented to be used, modified or considered by the examiner. It is on two pages, but may be removed and photocopied on one page, front to back, for convenience. This review and these suggestions in no way replace the skill and judgement of the experienced physician or examiner, but rather, it presents a rational approach to an assessment consistent with the individual who plans to undertake a wilderness venture.

APPENDIX Predictors of Success or Failure in Wilderness Venture

Method: To assist in identifying outcome predictors which could be recognized by physician examination and interview, we sought the opinion of health professionals, wilderness leaders, organizations and testing centers. Two hundred fifteen (215) questionnaires were sent. Sixty six (66) were returned. Six (6) were discarded because the responses were inadequate for scoring. Data was derived from sixty (60) respondents. Results: Results of the questionnaire are displayed in the Questionnaire Response Summary. (Tables 9 A, B, C, D) The number and percentage of respondents who would include each of the various characteristics in an examination are displayed in Column one of the Summary.

The Relative Value in absolute and in relative terms is recorded in the Questionnaire Response Summary, Tables 9 A, B, C, D. The Absolute Scale of Value was derived from the sum of the products of the respondents perceived unit value of importance (0=no value; 1=minimal value; 2 =moderately valuable; 3=very valuable) for each characteristic, multiplied by the number of responses for each. This Absolute Scale, (AS), ranged from 0 to 156 and is normalized to a scale of 1 to 100 for the Relative Value Scale (RVS). The highest RVS for the best “predictor of successful wilderness venture” was “a history of successful similar ventures”, (AS=151; RVS=97). The highest RVS for the best “predictor of failure on a wilderness venture was “demonstrated problems with psychological or interpersonal relationships” (AS=156; RVS=100). The least valuable predictor of success (speed run, AS=21; RVS=13) and of failure (speed run AS=23; RVS=15) reflect the lack of enthusiasm among examiners toward requiring demonstration of physical competence by the prospective participant. Most examiners would include most characteristics listed in their examination format reflecting a clinician’s thirst for information. Forty-four, (73%), felt history was more important than physiologic testing. Forty-five, (75%), would not include a speed run; 33, (55%), would not include the Hypoxic Ventilatory Response (HVR); and 29, (48%), and would not include a graded Exercise Test (GXT) or V02 Max. (Table 10)

Medical Assessment Worksheet: A medical recording worksheet based on the results of this review is provided at the conclusion of the Appendix for use by the examiner. Notice that the categories of components are used as an outline to help organize the data derived from the examination. This approach lends itself well to computer programming. It is not the only recommended form, nor is it the “official” form of any organization or individual, but is presented as a framework on which others can build.

Conclusions: Experts in the field of wilderness medicine and outdoor leadership were surveyed in order to examine the type of assessment which might be of help in planning wilderness ventures and matching participants with activities which would be within their range of safety. From the results a medical assessment form was designed that could be modified by venture leaders for their use. The results of this survey underscore the importance of the history and interview in completing a physician examination for prospective candidates for wilderness activities. An experienced successful participant has usually proven the capacity to function and succeed and to have the wisdom and judgment

to avoid circumstances beyond his or her personal capabilities. An experienced outdoor physician can recognize the participant’s judgment and stability and can be helpful in advising and designing a safe and satisfying wilderness venture that matches the characteristics of the participant with the planned activity.

REFERENCES

(1) Erb, B.D. Medical Selection of Participants in Wilderness Ventures. Syllabus, Wilderness Medical Society Annual Meeting, 1995, p. 489.

(2) Erb, B.D. Predictors of Success in Wilderness Ventures: Physical Activity, the Environment, and Fatigue, Wilderness Medicine Letter, 1990:7:8.

(3) Erb, B.D. Elders in the Wilderness, in Wilderness Medicine, Auerbach,

P.S.,editor, p.1807–1808, St. Louis, Mosby, 2001.

(4) Oertel, M.J. Ueber Terrain-Curorte zur Behandlung von Kranken mit

Kreislauf-Stoerungen, Verlag von FCW Vogel, Leipzig, 1886.

WILDERNESS MEDICALASSESSMENT Exam Code ______

I. PERSONAL Name:Last_____________________First________MI_____ Classification Venture Participant Address:______________________City________State____Zip______ A. Extreme 1. Extreme Telephone # Home: (____)____________Work: (____)____________ B. High 2. High Fax (____)______________E-mail address: _____________________ C. Recreation 3.Deconditioned Age_____ Gender_____Occupation____________________________ D. Therapeutic 4.RiskFactors Education (highest)_________________________________________ 5. Manifestly Ill

II. HISTORICAL 1.Have you ever participated in:

A wilderness venture? Yes_____ No_____ Desert activities? Yes_____ No_____ Similar to this activity? Yes_____No_____ Jungle activities? Yes_____No_____ Mountaineering? Yes_____ No_____ Canoeing? Yes_____ No_____ Above 10,000 feet? Yes_____ No_____ Kayaking? Yes_____ No_____ Backpacking? Yes_____ No_____ Marineactivities? Yes_____ No_____ Nordic skiing? Yes_____ No_____ Other? Yes_____ No_____

2.Medical problems with any of the above?_________________________________________________ __________________________________________________________________________________

3.Did you volunteer? Yes_____No_____ Were you recruited? Yes_____No_____

4. Do you now or have you everused: Tobacco? Yes_____ No_____ Alcohol? Yes_____No_____ Drugs? Yes_____No_____ Steroids? Yes_____No_____

5.Have you ever had previous significant medical illness? Yes_____No_____ Please describe:_____________________________________________________________________

6.Any problemswith psychosocial orinterpersonal relationships? Yes_____ No_____ Please describe:_____________________________________________________________________

7.Haveyou had previous surgicaloperations? Yes_____ No_____ Please describe:_____________________________________________________________________

8.Have youhad immunizations for: Tetanus? Yes_____No_____ Yellow fever?Yes_____No_____ Typhoid? Yes_____No_____ Hepatitis A? Yes_____No_____ Flu? Yes_____No_____ Hepatitis B? Yes_____No_____ Pneumonia? Yes_____No_____ Other? Yes_____No_____

9.Has anybody in your family had? Diabetes? Yes_____ No_____ Heart Disease? Yes_____ No_____ High Blood Pressure? Yes_____No_____ Bleeding Disorder?Yes_____No_____

10. Are youphysically active? Yes_____No_____ Exercise program?Yes_____No_____ Please describe:_____________________________________________________________________

III. MEDICAL ASSESSMENT

Height_________Weight__________ Blood Pressure__________ RestingHeart Rate__________

ITEM MEDICAL COMPONENTS NORMAL ABNORMALREMARKS 1 GeneralAppearance 2 Head, Neck, Face & Scalp 3 Nose & Sinuses 4 Mouth & Throat 5 Teeth & Gums 6 Ears 7 Eyes 8 Lungs 9 Breasts 10 Heart 11 Vascular—IncludeVaricosities 12 Abdomen—Include Hernia 13 Ano-rectal 14 Endocrine—IncludingThyroid 15 Genitalia 16 Upper Extremities 17 Lower Extremities 18 Spine 19 Skin & Hair 20 Neurologic 21 Lymph Nodes 22 Psychological

Laboratory: Hgb/Hct:_________________________________ UA:__________________________ Oher bloodstudies? Yes (please describe)_________________________________________ No_____

IV. PHYSIOLOGICALDATA:

GRADED EXERCISE TEXT: Protocol:___________________ HR (rest): _____ BP (rest):_____

PWC (max METs) Observed:________ VO2 max___________ HR (rest): _____ BP (rest):_____

PWC (maxMETs)Predicted:________ VO2 max___________ HR (rest): _____ BP (rest):_____ CONCLUSION:____________________________________________________________________

PULMONARY FUNCTION TESTS: ___________________________________________________ HYPOXICVENTILATORY RESPONSE: _______________________________________________ OTHER:___________________________________________________________________________

V.PSYCHOLOGICAL EVALUATION

PSYCHO-PHYSIOLOGIC SRESS ASSESSMENT: 1. Serial 7SubtractionTest: BP before:________ BP after:_________ HRbefore:________ HRafter:_________

2. Cold Pressor Test: BP before:________ BP after:_________ HRbefore:________ HRafter:_________

INTERVIEW AND SUMMARY: ________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________