Health History And Examination Form
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2Sequanota Lutheran Conference Center and Camp
Health History and Examination Form
(To be completed by parents/guardians of those under 18 years, or by adult campers or staff member themselves.)
Name________________________________________Birthdate_______________Sex_______Age________
Last
First
Initial
Parent or Guardian (or spouse)_______________________________________________________________
Last
First
Initial
Home Address____________________________________________________Phone____________________
Street & Number
City
State
Zip
Area/Number
Business Address_________________________________________________Phone____________________
Street & Number
City
State
Zip
Area/Number
Second Parent/Guardian/Emergency Contact___________________________________________________
Last
First
Initial
Home Address___________________________________________________Phone____________________
Street & Number
City
State
Zip
Area/Number
Business Address________________________________________________Phone_____________________
Street & Number
City
State
Zip
Area/Number
If not available in an emergency, notify________________________________________________________
Last
First
Initial
Address_______________________________________________________Phone______________________
Street & Number
City
State
Zip
Area/Number
Insurance: Do you carry family/medical/hospital insurance? Yes__ No__
Allergies: (Check Boxes)
Health Insurance Co._________________________________________
[ ] Environmental Allergies
Policy or I.D.#__________________________________________
[ ] Ivy Poison
Group Plan I.D.#________________________________________
[ ] Insect Stings
[ ] Peanuts
Carrier Address_________________________________________
[ ] Food
Doctor’s Name ___________________________Phone _____________
[ ]Medications
_____________________________
For Females:
_____________________________
Has this person menstruated?____If not, has she been told about it?___
_____________________________
Health History:
If so, is her menstrual history normal?_____Special Considerations___
[ ]Asthma
[ ] Frequent Ear Infection
Activity Restriction:__________________________________________
[ ] Heart Defect/Disease
___________________________________________________________
[ ] Epileptic Seizures
[ ] Diabetes
[ ] Bleeding/Clotting Disorders
Dietary Restrictions/Food Allergies:________________________________
[ ] Hypertension
____________________________________________________________
[ ] Mononucleosis
[ ] Chicken Pox
Current Medications (send in original containers w/ instructions):______
[ ] Measles
______________________________________________________________
[ ] German Measles
[ ] Mumps
[ ]Whooping Cough
(Dose and dosing times need to be discussed with nurse.)
[ ]Hepatitis
Please include a list of previous medical conditions/treatments:
____________________________________________________________________________________________
____________________________________________________________________________________________
Please include a list of any current physical, mental, or psychological conditions requiring medication, treatment, or
special restrictions or considerations while at camp:___________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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