Camper Health History

1973 N. 35th Road, Ottawa, IL 61350

Camper Health History

To Parent(s)/Guardian(s): Please follow the instructions below. Add additional information if needed.

Please complete this form. This is health history information and does not require a doctor's signature. This form must be completed and received prior to arrival at camp.

Camper Information

First Name

Last Name

Gender Male Female

Birthdate

Age at Camp

Grade in September

New Camper? Yes No

Return Camper # of Years

Number of Brothers

Number of Sisters

Any special pets?

If yes, what kind and name

Address City State Zip Code

Parent/Guardian with Legal Custody

To be contacted in case of emergency.

Name Relationship to Camper Parent Marital Status Married Divorced Who Has Legal Custody Preferred Phone 1 Preferred Phone2 E-Mail Address (if different from above) City State Zip Code

Second Parent/Guardian

Second Parent/Guardian or Other Emergency Contact

Name Relationship to Camper Preferred Phone 1 Preferred Phone2 E-Mail Address (if different from above) City State Zip Code

Additional Contact

In the event the parent(s)/guardian(s) cannot be reached.

Name Relationship to Camper Preferred Phone 1 Preferred Phone2

Health & Nutrition

Allergies No Known Allergies Food Medicine Environment (stings, hayfever, etc.) Other Describe Allergies Diet Regular Diet Regular Vegetarian diet Lactose Intolerant Gluten Intolerant Other (Please Specify) Describe Other Diet Restrictions I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptions
Describe Restrictions

Medical Insurance Information

This camper is covered by family medical/hospital insurance Yes No Insurance Company Policy Number Subscriber Insurance Company Phone Number

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 heath 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 injection, anesthesia, or surgery for this child. I understand that the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy 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 of Custodial Parent/Guardian Date Relationship to Camper Religious Restriction

Page 2 Health History Form

Immunization History: Provide the month and year for each immunization. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form.

Add Dates for Month/Year

Diptheria, tetanus, pertussis (DTaP) or (TdaP)

Dose 1 Date

Dose 2 Date

Dose 3 Date

Dose 4 Date

Dose 5 Date

Varicella (chicken pox)

Dose 1 Date

Dose 2 Date

Had Chicken Pox Date

Tetanus booster * (dt) or (TdaP)

Most Recent Date

Mumps, Measles, Rubella (MMR)

Dose 1 Date

Dose 2 Date

Dose 3 Date

Polio (IPV)

Dose 1 Date

Dose 2 Date

Dose 3 Date

Dose 4 Date

Haemophilus Influenzae type B (HIB)

Dose 1 Date

Dose 2 Date

Dose 3 Date

Dose 4 Date

Pneumococcal (PCV)

Dose 1 Date

Dose 2 Date

Dose 3 Date

Dose 4 Date

Hepatits B

Dose 1 Date

Dose 2 Date

Dose 3 Date

Hepatits A

Dose 1 Date

Dose 2 Date

Meningococcal Meningitis (MCV4)

Dose 1 Date

Tuberculosis (TB) test

Test Date

Testresult Negative Positive

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.

Signature

Date

Relationship to Camper

“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/container's. Many states require original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.

Medication Status This camper will not take any daily medications while attending camp.
This camper will take the following daily medication(s) while at camp.

Medication 1

Name of Medication Date Started Reason for Taking When is it given? Breakfast Lunch Dinner Bedtime Other Time Amount or Dose Give How is it given?

Medication 2

Name of Medication Date Started Reason for Taking When is it given? Breakfast Lunch Dinner Bedtime Other Time Amount or Dose Give How is it given?

Medication 3

Name of Medication Date Started Reason for Taking When is it given? Breakfast Lunch Dinner Bedtime Other Time Amount or Dose Give How is it given?

Name of Medication

Date Started

Reason for Taking

When is it given? Breakfast Lunch Dinner Bedtime Other Time

Amount or Dose Give

How is it given?

The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Check those that the camper should not be given.

List of Non-Prescription Meds Acetaminophen (Tylenol)
Ibuprofen (Advil. Motrin)
Phenylephrine decongestant (Sudafed PE)
Pseudoephedrine decongestant (Sudafed)
Antihistamine/allergy medicine
Guaifenesin cough syrup (Robitussin)
Diphenhydramine antihistamine/allergy medicine (Benadryl)
Dextromethorphan cough syrup (Robitussin DM)
Sore throat spray Generic cough drops
Calamine lotion
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)

General Health History

Check “Yes” or “No" for each statement. Explain “Yes” answers below.

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/menstruation? Yes No

15. Have problems with falling asleep/sleepwalking? Yes No

16. Ever had back/joint problems? Yes No

17. Have a history of bedwetting? Never Seldom Frequent

If so, precautions to be taken

18. Have problems with diarrhea/constipation? Yes No

19. Have any skin problems? Yes No

20. Traveled outside the country in the past 9 months? Yes No

21. Is camper a sleepwalker? Never Seldom Frequent

If so, precautions to be taken

22. Is camper afraid of? Dark Animals Water Lightning Thunder Other

23. Does camper: make friend easily fairly easily with difficulty

24. Does/Is Camper tire easily nervous irritable sullen easy going full of energy lacking pep over-achiever argues easily pick on bullys others

Yes Answers Explanation

Please explain "Yes" answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. (E.g. #21 - don't put near a door.)

Yes Explanation

Mental, Emotional, and Social Health:

Check “Yes” or “No” for each statement.

Has/does the camper:

1. Ever been treated for attention defcit disorder (AEBD) or attention defcit/hyperactivity disorder (AD/HD)? Yes No

2. Ever been treated for emotional or behavioral diffculties or an eating disorder? Yes No

3. During the past 12 months, seen a professional to address mental/emotional health concerns? Yes No

4. Had a signifcant life event that continues to affect the camper's life? Yes No

Yes Explanation

Name of camper's primary doctor(s):

Phone

Name of Dentist(s)

Phone

Name of Orthodontist(s)

Phone

What Have We Forgotten to Ask?

Please provide in the space below any additional information about the camper's health that you think important or that may affect the camper's ability to fully participate in the camp program. Attach additional information if needed.

Yes Explanation

Thank you for filling out the Camper Health History Form. We appreciate your cooperation in helping us to provide your child(ren) with the best possible experience at Camp Tuckabatchee!

See you at camp!