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Last Name __________________________ First Name ________________________
Home Phone _______________________ Other Phone ___________________wk/cell
Emergency Contact ________________________________Phone ________________
CAMPER HEALTH RECORD
SECTION 1 – HEALTH HISTORY YES NO Are there any problems in areas listed below? 1. Allergies or reactions: (food, medication, other) _____ _____ 2. Hay fever, asthma, or wheezing _____ _____ 3. Eczema or frequent skin rashes _____ _____ 4. Convulsions or seizures _____ _____ 5. Heart trouble _____ _____ 6. Diabetes _____ _____ 7. Frequent colds, sore throats, earaches (4+/yr) _____ _____ 8. Trouble passing urine or bowel movement _____ _____ 9. Shortness of breath _____ _____ 10. Speech problems _____ _____ 11. Menstrual problems _____ _____ 12. Dental problems (date of last exam __________) _____ _____ 13. Date of last tetanus booster ________________ 14. Are all immunizations up to date? _____ _____
Please explain any problems areas identified above___________________________________
Does this person have any infectious diseases? _____ _____
If yes, please explain. __________________________________________________________
____________________________________________________________________________
Is this person currently taking any medication _____ _____
If yes, please list and/or explain. __________________________________________________
SECTION 2 – MEDICAL EMERGENCY CARE AUTHORIZATION
Physician Name ___________________________________ Phone ____________________
Address _____________________________________________ Zip ___________
Insurance Company _____________________________ Policy # ______________________
I hereby give permission to the camp director and/or designee to secure emergency medical treatment and/or routine non-surgical medical care for the minor child listed above while attending camp. Yes _________ No ___________
Signature ___________________________________________ Date ____________________ |
