Hhsc Camper/ Staff Health History Form 1/2 Page 2
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2HHSC CAMPER/ STAFF HEALTH HISTORY FORM 2/2
Summer 20___Session:___
(Parents to fill out this form)
Camper Name:__________________________________________________________________
Last
First
Middle
Non-Prescription Medications: 1. Daily Non-Prescription medications __yes __no
(This includes over the counter, vitamins, natural remedies, and as needed medications)
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
Health History:
General Health history: Has he/she:
yes
no
Mental, Emotional, and Social Health: Has
yes
No
he/she:
1.
Ever been hospitalized?
1.
Ever been treated for attention deficit disorder
(ADD)?
2.
Ever had surgery?
2.
Ever been treated for emotional and/or behavioral
disorder or eating disorder?
3.
Have a recurrent/ chronic illness?
3.
Over the past 12 months, seen a professional for
any of the above?
4.
Have a history of bedwetting?
4.
Had any other issues, you would like us to know?
5.
Had a recent injury?
6.
Had asthma/ wheezing/ shortness of breath,
required an inhaler.
7.
Had seasonal/ environmental allergies?
8.
Have diabetes?
9.
Had a seizure?
10. Had fainting or dizziness?
11. Passed out/ had chest pain with exercise?
Please explain “yes” answers in space provided or on a separate page.
(The camp may contact you for any additional information.):
________________________________________________________________________________
________________________________________________________________________________
Recommendations and Restrictions while at camp:
1. Allowed to Swim: __yes __no
2. He/ She may participate in all camp activities, with the following restrictions
(which parents will be responsible for discussing
: _______________________________
with camp staff/ counselor upon arrival to camp, to assure these restrictions are able to be met
________________________________________________________________________________________________
Medical Insurance Information:
This camper is covered by family medical/hospital insurance □ Yes □No
Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company_____________________________________ Policy Number ___________________________
Subscriber_________________________________ InsuranceCompany Phone Number (______)___________________
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The
person described has permission to participate in all camp activities except as noted by me and/or an examining
physician. I give permission to the medical provider selected by the camp to order x-rays, routine tests, and
treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be
reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and
order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a
"need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has
permission to obtain a copy of my child’s health record from providers who treat my child and these providers
may talk with the program’s staff about my child’s health status.
Signature of Parent/ Guardian: ______________________________________Date: ___________
Name of Parent/Guardian: __________________________________ Relationship: ______________
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