Health History & Information
The following information must be filled in by the parent/guardian, or adult camper or staff member. The intent of this information is to provide camp health care personnel the background to provide appropriate care. Any changes to this form should be provided to camp health personnel upon participant's arrival to camp. Please provide complete information so that the camp can be aware of your health needs. The information on this form is not part of the camper or staff acceptance process, but is gathered to assist us in identifying appropriate care.
The health history portion must be filled out by parents/guardians of minors or by adults themselves
Name: ________________________________________________________ Birthdate: ________________
Home Address: _____________________________________________________________________________Street Address City State/Prov. Zip
Custodial parent/guardian(s)):Name ______________________ Phone: (h)________________ (w)________________ (cell)_______________
Name ______________________ Phone: (h)________________ (w)________________ (cell)_______________
Other Emergency Contact Name: ________________________________ Home Phone: _________________
Relationship to Camper : ____________________________ Other Phone: ___________________
Name of family physician _______________________________________ Phone: ________________________
Care Card Number:________________________________________________
Which of the following has the camper had?
MeaslesChicken PoxGerman MeaslesMumpsHepatitis AHepatitis BHepatitis CTB Test
PLEASE GIVE DATES OF IMMUNIZATION FOR: DTP ______________________________ TD (tetanus/diphtheria) ______________________________ Tetanus ______________________________ Polio ______________________________ MMR ____________________________________ Measles ______________________________ Mumps ______________________________ Rubella ______________________________ Haemophilus influenza B ______________________________ Hepatitis B ______________________________ Varicella (chicken pox) ______________________________ ALLERGIES Describe reaction and management of reaction Medication Allergies_______________________________________________________________ _________________________ ______________________________________________________ _________________________ ______________________________________________________ Food Allergies _________________________ ______________________________________________________ _________________________ ______________________________________________________ Other Allergies (include insect stings, hay fever, asthma, animal dander, etc.) _________________________ ______________________________________________________ _________________________ ______________________________________________________ MEDICATIONS CURRENTLY BEING TAKEN (Meds brought to camp must be in their original labelled pharmacy container.) Med #1 ______________________ Dosage __________ Specific times taken each day __________________ Reason for taking ______________________________________________________________________ Med #2 ______________________ Dosage __________ Specific times taken each day __________________ Reason for taking ______________________________________________________________________ Med #3 ______________________ Dosage __________ Specific times taken each day __________________ Reason for taking ______________________________________________________________________ Attach additional pages for more medications. Identify any medications taken during the school year that participant does/may not take during the summer: __________________________________________________________________________________ __________________________________________________________________________________ GENERAL QUESTIONS (Explain "yes" answers below.) Has/does the participant:
1. Had any recent injury, illness, or disease?
2. Have a chronic or recurring illness/condition?
8. Wear glasses, contacts or protective eye wear?
10. Ever passed out during or after exercise?
11. Ever been dizzy during or after exercise?
13. Ever had chest pain during or after exercise?
15. Ever been diagnosed with a heart problem?
19. Have any skin problems? (i.e., itching, rash, hives, acne)?
23. Had problems with diarrhea/constipation?
25. If female, have an abnormal menstrual history?
26. Ever had emotional/psychiatric difficulties for which help was sought?
Explanations OVER-THE-COUNTER MEDICINES Please circle yes or no for the over-the-counter medication that your child is permitted to take. Tylenol Products OTHER CAMPER INFORMATION We want your camper to have the best possible experience while at St Arseny Camp.
All information is regarded as STRICTLY CONFIDENTIAL and will only be shared with the staff who work with your camper and other necessary personnel (Camp Director, Nurse, Food Service Director, etc.) as appropriate.
.What is your child looking forward to at camp? ___________________________________________________
.Are there special fears, worries or concerns your child has about camp (extreme shyness, afraid of the dark, etc.)?__________________________________________________________________________________________
.Are there circumstances in your child's life that would be helpful for us to be aware of (i.e., death of a close relative, divorce, or other family trauma, etc.)? Please provide relevant details. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
.My camper is under the legal custodial care of:
Please provide all relevant details: ________________________________________________________________________________________________________________________________________________________
Please note that if any restrictions regarding parental access to the camper are to be observed by the Camp, we must be notified via court order, addressed specifically to St Arseny Camp.
Use this space to provide any additional information about the participants behaviour and physical, emotional, or mental health about which the camp should be aware.
REVISTA DE LASOCIEDAD CHILENA DEOBSTETRICIA Y GINECOLOGIAINFANTIL Y DE LA ADOLESCENCIAPolycystic Ovary Syndrome In Teenagers: Clinical, Laboratory and Ultrasound Evaluation and Treatment. / Sotomayor Karina y cols. Polycystic Ovary Syndrome In Teenagers: Clinical, Laboratory and Ultrasound Evaluation and Treatment. p.024 Sotomayor Karina, Barrera C., FlÃ¡ndez J. Centro de Docencia de AtenciÃ
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