Camp Health Screening Form
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1CAMP OAKHURST HEALTH SCREENING FORM
CAMP DATES______________________
CAMPER’S NAME:___________________________________________________________________________________________________________________
AGE:_______________________________________________________ DATE OF BIRTH:________________________________________________ SEX: M / F
CHURCH/CITY:______________________________________________________________________________________________________________________
PARENT/GUARDIAN’S NAME AND PHONE:______________________________________________________________________________________________
IF YOU OBSERVE ANY ILLNESS, COMMUNICABLE (INFECTIOUS) DISEASE, OR INJURY AS
LISTED BELOW IN THE THREE BOXES, DESCRIBE THE ITEM THAT WAS CIRCLED ON THE LINES
PROVIDED BELOW.
B.
A.
C.
COMMUNICABLE DISEASE
ILLNESS (in the last 48 hours)
INJURY EXAMPLES:
EXAMPLES:
MAY INCLUDE:
CASTED FRACTURES,
MEASLES, MUMPS, RUBELLA, POLIO,
NAUSEA, VOMITING,
RECENT HEAD INJURIES,
HEPATITIS, TETANUS, DIPTHERIA,
DIARRHEA, FEVER,
AND/OR LACERATIONS
MENINGITIS, PERTUSSIS, INFLUENZA,
SORE THROAT, RASH,
THAT HAVE STITCHES OR
TUBERCULOSIS
OPEN
STAPLES –
ACTIVE
SORES, PINK EYE,
MUST BE
(ON MEDICATION)
COUGH NOT RELATED TO
CLEARED BY DOCTOR
OR
ASTHMA
INACTIVE (NEGATIVE CHEST X-RAY)
If any items are circled in either column A or B please have the individual refrain from coming to camp.
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
*ALL ABOVE INFORMATION WILL BE KEPT CONFIDENTIAL AND ONLY SHARED WITH CAMP OAKHURST STAFF OR YOUR CHURCH COUNSELOR,
IN ORDER TO PROVIDE ADEQUATE HEALTH CARE FOR YOUR CHILD WHILE AT CAMP. THANK YOU.
SIGNATURE OF HEALTH SCREENER:_______________________________________________________________________________________Date ___________________________
Official Use:
Reviewed
/
/
Supervisor _____________________________________________________________________________________
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Parent category: Medical