Hhsc Camper/ Staff Health History Form 1/2
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2HHSC CAMPER/ STAFF HEALTH HISTORY FORM 1/2
Summer 20___Session:___
(Parents to fill out this form)
Camper/ Staff Name: ______________________________________________________________
Last
First
Middle
□Male
□Female Birth Date: _________________ Age on arrival at camp: _______________
Month/Day/Year
Contact Information:
Camper Home Address:____________________________________________________________________________
Street Address
City
State
Zip Code
Parent/guardian with legal custody to be contacted in case of illness or injury:
Name: ____________________________________Relationship to Camper: _______ Home phone: ________________
Cell phone: ____________________ Email: ____________________________________________________________
Second parent/guardian or other emergency contact:
Name: ____________________________________Relationship to Camper: _______ Home phone: ________________
Cell phone: ____________________ Email: ____________________________________________________________
Additional contact in event parent(s)/guardian(s) cannot be reached:
Name: ____________________________________Relationship to Camper: _______ Home phone: ________________
Cell phone: ____________________ Email: ____________________________________________________________
Allergies:
__ No known allergies
allergic to: __food __medicine
__environment __Insect bites __other
(Please describe what he/she is allergic to and describe the reaction): ________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Immunization History:
Provide the most recent dates. The * ones must be current:
Test
Date Last given
Test
Date Last given
Diptheria, tetanus, pertussis *
Haemophilus influenza B (HIB)
(DTaP or TDaP)
Mump, measles, rubella (MMR)*
Pneumococcal (PCV)
Polio (IPV) *
Tuberculosis test (TB) (PPD)
__neg __positive
Varicella (chickenpox) *
Had chicken pox, Date:_________
Meningococcal meningitis *
Prescription Medications: 1.Daily Prescription medications __yes __no
(Must be brought to camp in original bottle from pharmacy, to include pharmacy label, otherwise cannot be given)
Medication name
Reason for taking it
Dosage (include mg)
When is it to be given
How is it given (oral,
inhaled, nasal, etc…)
__ breakfast __ lunch
__ dinner
__ bedtime
__ breakfast __ lunch
__ dinner
__ bedtime
__ breakfast __ lunch
__ dinner
__ bedtime
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Parent category: Medical