Summer Camp Health Questionnaire Form

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University of Michigan Summer Camp Health Questionnaire
(To be filled out by Participant’s Parent or Guardian)
Participant: _________________________________________________________ Birth date: _______/_______/_______ Sex: M F
Address: ______________________________________________________________ Phone: (
) __________-______________
Family Physician: ______________________________________________________ Phone: (
) __________-______________
Parent/Guardian name(s): _______________________________________________
Medications: indicate medication(s) which taken on a regular basis:
Medication Name: _____________________________ Dosage: _____________ Directions: ____________________________
Medication Name: _____________________________ Dosage: _____________ Directions: ____________________________
Note: Participant should bring an adequate supply of their medication(s) with them.
Explain any “yes” answers below:
Yes
No
Nervous System: Has the participant ever:
1.
had a head injury?.................................................................................................................................................
2.
been knocked out or unconscious?.......................................................................................................................
3.
had a seizure?............................................................................................................... .........................................
4.
had a stinger, burner, or pinched nerve?...............................................................................................................
5.
had any problems with his/her eyes or vision?.....................................................................................................
6.
worn glasses, contacts or protective eyewear?.....................................................................................................
Circulation: Has the participant ever:
7.
been dizzy or passed out during or after exercise?...............................................................................................
8.
had chest pain during or after exercise?...............................................................................................................
9.
tired out more quickly than their friends during exercise?...................................................................................
10.
been told he/she has a heart murmur?.................................................................................................................
11.
had racing heart or skipped heartbeats?...............................................................................................................
12.
had anyone in their family died of heart problems or sudden death before age 50?............................................
Respiratory:
13.
Does the participant ever have trouble breathing or cough during or after exercise?........................................
Musculoskeletal:
14.
Does he/she frequently have heat or muscle cramps?........................................................................... ..............
15.
Does he/she use any special equipment (pads, braces, neck rolls, mouth guards, etc.)?......................................
16.
Has she/he had any injuries of any bones or joints?.......................................................................... ...................
 Head
 Chest
 Shoulder
 Elbow
 Wrist
 Hip
 Knee
 Ankle
 Neck
 Back
 Forearm
 Hand
 Thigh
 Calf
 Foot
17. Skin: Does she/he have any skin problems (itching, rashes, acne, etc.)?...................................................................
General:
18.
Has he/she ever had surgery or been hospitalized?............................................................................ .................
19.
Has he/she had any other medical problems (infectious mono, diabetes, high blood pressure, etc.)?................
20.
Is he/she taking any medications or pills?...........................................................................................................
21.
Does he/she have any allergies (medicines, bees or other stinging insects)?......................................................
When was the participant’s last tetanus shot?___________________________________________________
22.
When was the participant’s last measles immunization?__________________________________________
23.
Females only (optional):
When was the participant’s first menstrual period?______________________________________________
24.
When was the participant’s last menstrual period?______________________________________________
25.
What was the longest time between the participant’s periods last year?_______________________________
26.
Explain “Yes” answers:
____________________________________________________________________________________
____________________________________________________________________________________
I hereby state that, to the best of my knowledge, my answers to the above questions are correct.
Signature of Participant: ______________________________________________________
Date: _______/_______/_______
Signature of Parent/Guardian: _________________________________________________
Date: _______/_______/_______

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