Scribd
Upload
384 views2 pages

Health Form

This document is a health history form for a camper attending NeKaMo Camp. It collects information such as the camper's name, date of birth, emergency contacts, health history including any relevant medical conditions, illnesses, surgeries, allergies, and immunization history. The parent or guardian must sign the form to authorize medical treatment during camp and provide consent for the camp to administer medications or seek further treatment if necessary.

Uploaded by

amanda6254
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
384 views2 pages

Health Form

This document is a health history form for a camper attending NeKaMo Camp. It collects information such as the camper's name, date of birth, emergency contacts, health history including any relevant medical conditions, illnesses, surgeries, allergies, and immunization history. The parent or guardian must sign the form to authorize medical treatment during camp and provide consent for the camp to administer medications or seek further treatment if necessary.

Uploaded by

amanda6254
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

NeKaMo

Camp HEALTH HISTORY FORM

To be filled in by camper’s parent/guardian or staff member.

Name_________________________________________________________________________________________
Last First Middle
Date of Birth __________________________ Age ______ Sex _____________

Parent/Guardian (or Spouse) ______________________________________ Home Phone ( )______________

Home Address _________________________________________________ Work Phone ( )_______________

If not available in an emergency, notify:

Name ________________________________________________________ Home Phone ( )______________

Address ______________________________________________________ Work Phone ( )______________

OR Name ______________________________________________________ Home Phone ( )______________

Address ______________________________________________________ Work Phone ( )______________

HEALTH HISTORY: (check-–giving approximate dates)

Bleeding/Clotting Disorders ________ Diseases Allergies


Diabetes ________ Chicken Pox ________ Asthma ________
Ear Infections (frequent) ________ Whooping Cough ________ Food ________
Epilepsy or Convulsions ________ ______________ ________ Hay Fever ________
Heart Defect/Disease ________ ______________ ________ Insect Stings ________
High Blood Pressure ________ Ivy Poisoning, etc. ________

(For Female): Has this person menstruated? ________ Penicillin ________


If not, has she been told about it? ________ Other (list)
If so, is her menstrual history normal? ________ _______________ ________
Special considerations ___________________________________________ _______________ ________

List date(s) and describe:


Disability or chronic/recurring illness
_________________________________________________________________
Operations or serious injuries ______________________________________________________________________
Recent illness or hospitalization ____________________________________________________________________
Name of family physician ____________________________________________ Phone ( )__________________
Name of dentist/orthodontist _________________________________________ Phone ( )__________________
Name of family medical/hospital insurance carrier ______________________________________________________
Policy or group number ___________________________ Name on the policy _______________________________

AUTHORIZATION FOR TREATMENT MUST BE COMPLETED

This health history is correct so far as I know, and the person herein described has permission to engage in all
prescribed activities except as noted. I hereby give permission to the physician selected by the camp director to order
X-rays, routine tests, and treatment for the health of my child, and in the event I cannot be reached in an emergency, I
hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and
to order injection and/or anesthesia and/or surgery for my child as named above. This form may be photocopied for
use out of camp. I agree to the release of any records necessary for treatment, referral, billing, or insurance
purposes.
Signature ______________________________________________________________ Date ___________________

Witness _______________________________________________________________ Date ___________________

The back side of this form m ust be com pleted too!                


CURRENT MEDICATION:

Name of medication Dosage When taken Reason for taking

NOTE: ALL MEDICATION brought to camp (listed


above), including vitamins and supplements, must be in
ORIGINAL CONTAINERS with user’s name printed on
them and labeled with directions for use.

IMMUNIZATIONS-–Required immunizations must be determined locally. Record the date (month/year) of


immunization and/or most recent booster:

IMMUNIZATION Date Last Received IMMUNIZATION Date Last Received

DTP Series Tetanus

Measles Tuberculin test (most recent)

Mumps Other

Polio

Rubella (German Measles)

The applicant is under the care of a physician for the following condition(s): _________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Current treatment (not including medications listed on front page): _________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Medication to be administered at camp (if different from previous list on front page): __________________________
______________________________________________________________________________________________
Medically prescribed meal plan or dietary restrictions: __________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Any activity restrictions? (Swimming, diving, strenuous activity) ___________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

You might also like