Campers Health History (Page 2 of 2) in pdf

If this Camper is to be taking ANY medications during camp, it is essential that we have written instructions regarding

administration of these medicines from you, the parent / guardian. Please complete the following if this situation will

apply to your camper.

Camper’s Name ________________________________________________________________________________________

Medication(s) _________________________________________________________________________________________

Special care of medication (refrigeration, etc.) _______________________________________________________________

_____________________________________________________________________________________________________

Any special reactions / symptoms to watch for? ______________________________________________________________

_____________________________________________________________________________________________________

Refill information ______________________________________________________________________________________

Remarks _____________________________________________________________________________________________

_____________________________________________________________________________________________________

CamP use only

Camper’s Name ______________________________________________________________ Age ______________________

_____________

Examination of arriving camper / staff by Camp Health Supervisor.

_____________

Skin

special remarks / instructions

_____________

Eyes

_____________

Temperature

_____________

Throat

_____________

Ears

_____________

Other

_____________

Existing condition(s) to be watched closely _________________________________________________

_____________________________________________________________________________________________________

Date Examined _____________________________

_______________________________________________________

Signature of Health Supervisor

Campers Health History Page 2