Health History And Emergency Form - Wheaton Park District Page 2
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1
2Health History
The parent/legal guardian must fill in the following information. The intent of this information is to provide camp personnel the
background for appropriate care. Keep a copy of the completed form for your records.
ALLERGIES – List all known
Describe Reaction and Management of the Reaction
Medication Allergies (List)
______________________________________
___________________________________________________
Food Allergies (List)
______________________________________
___________________________________________________
Other Allergies (List) – include insect stings, hay fever, asthma, animal dander, bug spray, etc.
______________________________________
___________________________________________________
______________________________________
___________________________________________________
Restrictions (The following restrictions apply to this individual)
Does not eat:
Peanuts
Tree Nuts
Pork
Poultry
Seafood
Eggs
Dairy
Other
Please describe other:_______________________________________________________________________________
General Questions (Explain “yes” answers below)
1. Had any recent injury, illness or infectious disease? Yes
No
7. Ever had back problems?
Yes
No
2. Have a chronic or recurring illness/condition?
Yes
No
8. Ever had problems with joints?
Yes
No
3. Ever had a head injury?
Yes
No
9. Have any skin problems (rash, itching. Etc) Yes
No
4. Ever been knocked unconscious?
Yes
No
10. Have diabetes?
Yes
No
5. Wear glasses contacts or protective eyewear?
Yes
No
11. Have frequent headaches?
Yes
No
6. Ever been diagnosed with a heart murmur?
Yes
No
12.Ever have frequent ear infections?
Yes
No
Please explain any “yes” answers, noting the number of the question (s).
________________________________________________________________________________________________
My child is up-to-date on his/her immunizations: ____yes
____no
What is the month/year of your child’s tetanus shot? _______________________________(mandatory)
Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the
camp should be aware:
_____________________________________________________________________________________________
Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary, including swimming info):
_______________________________________________________________________________________________
My child is authorized to be picked up by the following person(s) from camp: (ID must be provided by person picking up)
1.
__________________________________ Relationship_____________Phone # ___________________
2.
__________________________________ Relationship_____________Phone # ___________________
3.
__________________________________ Relationship_____________Phone # ___________________
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