Medical History Form printable pdf download

Medical History Form

Please submit this form and a photocopy of your insurance card (front & back).

Don’t forget your card – your child may need it!

Name ______________________________________DOB _________ Sex ___ Age ____Height_____Weight_____

Address__________________________________City__________________________State_______Zip__________

Known Drug

Allergies___________________________________________SS#_______________________________

Health History-

check any illness the camper has experienced

______ Asthma

_____ Allergies

______ Sinus Infections

______ Hospitalization

______ Headaches

_____ Dizziness/fainting ______ Heart trouble

______ Seizures

______ Urinary infection _____ Diabetes

______ Blood condition

______ Earaches

______ Surgeries

_____ Physical handicaps ______ Injuries

______ Eye condition

______ Breathing difficulties *Note: If you use an inhaler, you must bring it to camp with you…no exceptions!

1. Explain any of the conditions checked above &/or or any other condition:

2. Describe medications taken in the last 12 months for the condition checked:

3. Is your child currently taking any medication(s)? NO YES.

If yes, please state name of medication(s) and dosage. (

ALL PRESCRIPTION MEDICATIONS MUST BE IN THE

CONTAINER WITH THE PHARMACY LABEL)

4. What non-prescription medications do you give permission for your child to take while at camp?

(ANY

MEDICATIONS SENT WITH YOUR CHILD TO CAMP MUST BE IN A CONTAINER WITH IDENTIFICATION OF

MEDICATION AND DOSE TO BE GIVEN)

_______ Pain Relief or Fever Control (Tylenol, Advil, etc.) _______ Decongestant (Sudafed, etc.)

_______ Antihistamine (Benadryl, etc.) _______ Others

5. Does your child have any condition that limits physical activity or sports? NO YES

Describe:

6. Does your child wear any type of medical alert identification? NO YES (If yes, attach a note from

the physician for permission to attend this camp and an explanation of what is to be done in an emergency)

7. Date of last Tetanus injection (if unknown, please indicate such)

IN CASE OF AN EMERGENCY

Parent: _____________________________________ Home phone (_____)____________________________

Mobile phone: ________________________________ Work phone (_____)____________________________

Alternate person _____________________________ Contact phone(_____)____________________________

I HEREBY AUTHORIZE PHYSICIANS, NURSES AND ASSISTANTS OF THE LOCAL HOSPITAL TO

PERFORM ALL TREATMENTS AND PROCEDURES AS ORDERED AND DEEMED NECESSARY IN

CASE OF AN EMERGENCY UPON:

Camper(Print)______________________________ Parent/Guardian Signature______________________________

Relationship to Camper_______________________

Date__________________________

Mail to: FC Arkansas Camp, c/o Sherri Finley, 2530 NW 30

St., Newcastle, OK 73065

-or- fax toll free to: 1-866-702-1657

rev.03.03.12

Medical History Form

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