Camper Health History Form

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To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a
copy of your completed CAMPER HEALTH HISTORY FORM 1 to your child’s health-
CAMPER HEALTH
care provider for review.
HISTORY FORM 2
Dates will attend camp: from ______________________to_____________________
Month/Day/Year
Month/Day/Year
Camper Name: _______________________________________________________
First
Middle
Last
Bring this form with you to
Birth Date _______________________
Age on arrival at camp: ________
check-in when you are dropping
Month/Day/Year
off your camper.
Camper home address: _________________________________________________
If your camper has special dietary
____________________________________________________________________
or medical needs please contact
City
State
Zip Code
Oreon Millard, 800-474-1912 or
Custodial parent(s)/guardian(s) phone: (______)____________ (______)__________
,
Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.
BEFORE coming to camp.
The following non-prescription medications are
Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM 1 and
commonly stocked in camp Health Centers and
complete all remaining sections of this form (FORM 2). Attach additional
are used on an as needed basis to manage illness
information if needed.
and injury. Medical personnel: Cross out those
Physical exam done today:
Yes
No (If “No,” date of last physical: _________________)
items the camper should not be given.
Month/Day/Year
ACA accreditation standards specify physical exam within last 24 months.
Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Dextromethorphan
Weight: ________ lbs Height: ______ft______in
Diphenhydramine (Benadryl)
Generic cough drops
Blood Pressure________/________
Chloraseptic (Sore throat spray)
Allergies:
Lice shampoo or scabies cream (Nix or Elimite)
 No Known Allergies
Calamine lotion
 To foods (list):
Hydrocortisone 1% cream
Topical antibiotic cream
 To medications: (list):
Calamine lotion
 To the environment (insect stings, hay fever, etc.– list):
Aloe
 Other allergies: (list):
Describe previous reactions:
Diet, Nutrition: Eats a regular diet.  Has a medically prescribed meal plan or dietary restrictions:(describe below)
The camper is undergoing treatment at this time for the following conditions: (describe below)  None.
Medication:  No daily medications.  Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe
below)
Other treatments/therapies to be continued at camp: (describe below)  None needed.
Do you feel that the camper will require limitations or restrictions to activity while at camp?  No  Yes
If you answered “Yes” to the question above, what do you recommend? (describe below—attach additional information if needed)
“I have reviewed the CAMPER HEALTH HISTORY FORM 1, and have discussed the camp program with the camper’s
parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program
(except as noted above.)
Name of licensed provider (please print): _____________________________Signature: ______________________________Title: _______
Office Address_____________________________________________________________________________________________________
Street
City
State
Zip Code
Telephone: (________)_____________________ Date:_______________________

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