Summer Camp Health Information Form
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1
2Summer Camp Health Information Section
Must be forwarded 1 month before camp starts.
Please Attach Health Examination Form Provided by Child’s Physician
And Dated Within Two Years or Less from Camp Week’s Inception
In order to be informed of medical, physical or other needs/restrictions for your camper(s), parents are requested to complete
the following form for each camper. If we should refer to the data provided on child’s physician examination a copy of which
you are attaching to this form, please state so.
Camper’s Name: ________________________________________________________ Age: __________________
Weeks Attending Camp: ________________________________________________________________________
Parent /Guardian’s Name: ______________________________________________________________________
Contact Number: __________________________ E-mail: ____________________________________________
General Questions (Explain “yes” answers below)
Has/Did the participant:
1.
Had any recent injury, illness or infectious disease? Yes
No
16. Ever had back problems?
Yes
No
2.
Have a chronic or recurring illness/condition?
Yes
No
17. Ever had problems with joints?
Yes
No
3.
Ever been hospitalize?
Yes
No
18. Have an orthodontic appliance being brought to camp? Yes
No
4.
Ever had surgery?
Yes
No
19. Have any skin problems?
Yes
No
5.
Have frequent headaches?
Yes
No
20. Have diabetes?
Yes
No
6.
Ever had a head injury?
Yes
No
21. Have asthma?
Yes
No
7.
Ever been knocked unconscious?
Yes
No
22. Had mononucleosis in the past 12 months?
Yes
No
8.
Wear glasses, contacts or protective eye wear?
Yes
No
23. Has a problem with diarrhea/constipation?
Yes
No
9.
Ever had frequent ear infections?
Yes
No
24. Have problems with sleepwalking?
Yes
No
10. Ever passed out during or after exercise?
Yes
No
25. If female, have an abnormal menstrual history?
Yes
No
11. Ever been dizzy during or after exercise?
Yes
No
26. Have a history of bed wetting?
Yes
No
12. Ever Had seizures?
Yes
No
27. Ever had an eating disorder?
Yes
No
13. Ever had chest pain during or after exercise?
Yes
No
28. Ever had emotional difficulties for which
14. Ever had high blood pressure?
Yes
No
professional help was sought?
Yes
No
15. Ever been diagnosed with a heart murmur?
Yes
No
Please explain any “yes” answers, noting the numbers of the questions (use separate sheet of paper if necessary).
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Which of the following did participant have?
Measles ____ Chicken Pox____ German Measles____ Mumps____ Hepatitis A_____ Hepatitis B____ Hepatitis C____
Please give all dates of immunization for (write N/A if vaccine does not apply):
Vaccine
Date(s) /month/yr of vaccinations
:
DTP:
_______
________
________
________
________
TD:
_______
________
________
________
________
Tetanus:
_______
________
________
________
________
Polio:
_______
________
________
________
________
MMR:
_______
________
Or Measles:
_______
________
Or Mumps
_______
________
Or Rubella:
_______
________
Haemophilus Influenza B
_______
________
________
________
Hepatitis B:
_______
________
________
Varicella (chicken pox):
_______
________
Special Needs Notification:
In order to be informed of medical, physical or other needs/restrictions for your camper(s), parents are requested to complete the
following form for each registered camper. Please circle no or yes. Use back if more space is needed
Medical Allergies
No Yes Describe: ________________________________________________________
Food Allergies
No Yes Describe: ________________________________________________________
…/see back/…
Activity Restrictions:
No Yes Describe: ________________________________________________________
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