Microsoft word - camper+health1.doc

CAMPER HEALTH HISTORY FORM 1
Dates will attend camp: from____________________ to _________________________ Month/Day/Year Month/Day/Year Camper Name:___________________________________________________________ First Middle Last ___Male ___Female Birth Date ________________ Month/Day/Year ______________________________________________________________________________________ INSTRUCTIONS FOR PARENT/GUARDIAN
ATTACH ADDITIONAL INFORMATION IF NEEDED
1) Complete and make a copy 2) Send the original, signed Form 1 to camp by the requested date 3) Complete the top of the Health Care Provider Form 2 and provide a copy of Form 1 along with Form 2 to your child’s Health Care Provider for review and completion. 4) After having Form 2 completed and signed by your child’s health care provider, return Form 2 to camp by the requested date. _____________________________________________________________________ Camper Home Address__________________________________________________ Street City State Zip Parent/guardian with legal custody to be contacted in case of illness or injury Name:____________________ Relationship _________________Phone__________ To Camper Email________________ Home Address: _____________________________________________________________________ Street City State Zip Second/parent/guardian or other emergency contact: Name _____________________________ Relationship ___________________ Phone ___________ To Camper Email____________ __________________________________________________________________________________ CAMPER HEALTH HISTORY FORM 2
ALLERGIES: Check One _______ No Known Allergies
_______ Yes Allergic to
_______ Food _______ Medicine ______ Environment ( Insects, Hay fever, etc)
Describe allergies to and reactions seen:__________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Diet/Nutrition: Check one
____ Camper eats regular diet _____ Camper eats vegetarian diet ____ Camper needs special foods
(explain below)
__________________________________________________________________________________
__________________________________________________________________________________
Restrictions:

___ I have reviewed the program and activities of the camp and feel the camper can
participate without restriction.
___ I have reviewed the program and activities of the camp and feel the camper can
participate with the following restrictions. (Please explain below)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
CAMPER HEALTH HISTORY FORM 3

Medical Insurance Information:

Is camper covered by family medical/hospital insurance ___ Yes ____ No
(Include a copy of your insurance card if appropriate; copy both sides of the card
so information is readable.)
Insurance Company: _____________________________ Policy Number
___________________
Subscriber: _____________________________________ Insurance Company
Phone #_________
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to
whom it pertains. The person described has permission to participate in all camp
activities except as noted by me and /or an examining physician. I give permission to
the physician selected by the camp to order x-rays, routine tests, and treatment related
to the health of my child for both routine health care and in emergency situations. If I
cannot be reached in an emergency, I give my permission to the physician to
hospitalize, secure proper treatment for and order injections, anesthesia, or surgery for
this child. I understand the information on this form will be shared on a “need to
know” basis with camp staff. I give permission to photo copy this form. In addition,
the camp has permission to obtain a copy of my child’s health record from providers
who treat my child and these providers may talk with the program’s staff about my
child’s health status.
Signature _______________________________________ Date__________
Parent/ ________________________________
Guardian Relationship to Camper
If your camper has not been fully immunized, please sign the following statement. I
understand and accept the risks to my child from not being fully immunized.
__________________________________________ Date _____________
Signature
Relationship to Camper ________________________________________
CAMPER HEALTH HISTORY FORM 4

Medication:
The camper will not take any medication while attending camp __________
The camper will take the following daily medications while camping ________
This includes vitamins and Natural remedies.
Please review camp instructions about required packaging/containers. Provide
enough of each medication to last the entire time the camper will be at camp.

CAMPER HEALTH HISTORY FORM 5

The following non prescription medications will be stocked in the camp Health
Center and are used on an as needed basis to manage illness and injury.

Cross out those the camper should not be given.
Acetaminophen (Tylenol)
ibuprofen (Advil, Motrin)
Phenylephrine decongestant (Sudafed PE)
Pseudoephedrine decongestant (Sudafed)
Antihistamine/allergy medicine
Diphenhydramine antihistamine/allergy medicine (Benadryl)
Sore Throat spray
Lice shampoo or cream (Nix or Elimite)
Calamine lotion
Laxatives for constipation (Ex-Lax)
Guaifenesin cough syrup (Robitussin)
Dextromethorphan cough syrup (Robitussin DM)
Generic cough drops
Antibiotic cream
Aloe
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
General Health History: Check Yes or No for each statement.
Explain yes answers below:
Has/does the camper:
1. Ever been hospitalized ? ___Yes ___ No 2. Ever had surgery? ___ Yes ___ No 3. Have recurrent/chronic illnesses? ___ Yes ___ No 4. Had a recent infectious disease? ___ Yes ___ No 5. Had a recent injury? ___ Yes ___ No 6. Had asthma/wheezing/shortness of breath? ___ Yes ___ No 7. Have diabetes? ___ Yes ___ No 8. Had seizures? ___ Yes ___ No 9. Had headaches? ___ Yes ___ No 10. Wear glasses, contacts, or Protective eyewear? ___ Yes ___ No 11. Had fainting or dizziness? ___ Yes ___ No 12. Passed out/had chest pain during exercise? ___ Yes ___ No 13. Had Mononucleosis (“mono”) during the Past 12 months? ___ Yes ___ No 14. If female, have problems with periods CAMPER HEALTH HISTORY FORM 6
16. Ever had back/joint problems? ___ Yes ___ No 17. Have a history of bedwetting? ___ Yes ___ No 18. Have problems with diarrhea/constipation? ___ Yes ___ No 19. Have any skin problems? ___ Yes ___ No. 20. Traveled outside of the country in the Past 12 months? Where? ___ Yes ___ No Please explain “Yes” answers in the space below, noting the number of the questions. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1. Has the camper ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD) ___ Yes ___ No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? 3. During the past 12 months, seen a professional to address mental/emotional health 4. Had a significant life event that continues to affect the camper’s life? ___ Yes
Please explain yes answers below.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Health Care Providers:

___________________________________Phone#____________________ 2. Name of Dentist _____________________ Phone# ___________________ 3. Name of orthodontist: ___________________Phone#_________________
ADDITIONAL INFORMATION WE SHOULD KNOW ABOUT THIS CAMPER:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Parents/Guardians: STOP here. The rest of this form is completed when the camper
arrives at the camp. Keep a copy for your records.
CAMPER HEALTH HISTORY FORM 7
Initial Screening Date/Time ___________ Initials _________ _____ Screening has been conducted according to camp protocol and significant Findings noted as follows: A. Any signs/symptoms of illness or injury upon arrival? ___ Yes ___ No B. History of exposure to communicable disease? ___ Yes ___ No C. Additions or corrections to information on this health history?___ Yes ___ No D. Medication given to health care staff? ___ Yes ___ No Yes explained below: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Provider Notes: Date/Time/Initial all entries: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Exit Note: Check one of the following: _________ Left camp this day with no reported illness or injury symptoms: ________ Left camp this day with the following problem/concern: ________________________________________________________________________________________________________________________________________________________________________________________________________________________ This person was told about the problem and instructed about the follow up as noted above: Date/Time ___________ Initials ___________

Source: http://www.mdle.net/espa/pdf/camphealth.pdf