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St arseny health form.xls

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.

Source: http://www.starsenycamp.ca/wp-content/uploads/2008/05/St%20Arseny%20Health%20Form.pdf

cemera.cl

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