Health Form
Health History / Examination Form Dates of Camp Attendance ______________
for Children Attending Camps Mail the form to: Dreamcatcher Ranch
8434 Grizzly Flat Rd. Somerset, CA 95684
The information on the form is not part of the camper or staff acceptance process, but is gathered to assist us in identifying appropriate care. Health history must be filled out by parents/guardians of minors. The last page, Health exam must be completed by approved licensed medical personnel at least every two years. Yearly update required of any medical changes.
Name__________________________________ DOB ____________ Age at camp _______
Home address _______________________________________________________________
Street City State Zip
Custodial parent/guardian ______________________________Home Phone _______________
Address (if different) ________________________________________ Cell _______________
Business address _______________________________________ Bus. Phone ______________
Second parent or guardian or emergency contact _____________________________________
Address (if different) ____________________________________ Phone _________________
If not available in an emergency, notify:
Name ___________________________________________________________
Relationship ___________________________________________Phone ________________
Address ____________________________________________________________________
Street City State Zip
Insurance Information:
Is the participant covered by family medical/hospital insurance? ____ yes ____no
If so, indicate carrier or plan name _____________________________Group # ___________
***Photocopy of front and back of health insurance card must be attached to this form***
Important - The following must be complete for attendance*
*Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medication, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied.
Signature of parent/guardian of camper/staff __________________________________________
Printed Name ____________________________________________ Date __________________
*I also understand and agree to abide by any restrictions place on my participation in camp activities.
Signature of minor camper/staff ______________________________________Date ______________
*If for religious reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.
For office use only:
Name _________________________________ Session _____________Year ________
HEALTH HISTORY
The following information must be filled out by the parent/guardian and/or adult staff member. The intent of this information is to provide camp health care personnel the background to provide appropriate care. Keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel upon participant's arrival in camp. Provide complete information so that the camp can be aware of your needs.
ALLERGIES List all known. Describe reaction and management of the reaction.
________________________ _________________________________________
________________________ _________________________________________
________________________ _________________________________________
________________________ _________________________________________
Food Allergies (list)
________________________ _________________________________________
________________________ _________________________________________
________________________ _________________________________________
Other allergies (list)
________________________ _________________________________________
________________________ _________________________________________
RESTRICTIONS:
The following restrictions apply to this individual:
Dietary
_____ Does not eat red meat ____ Does not eat pork ____ Does not eat eggs
_____ Does not eat poultry ____ Does not eat seafood ____ Does not eat dairy products
_____ Other (describe) ____________________________________________________________________________________________________________________________________________________________________________
Explain any restrictions to activity (e.g. what cannot be done, what adaptation or limitation are necessary) ____________________________________________________________________________________________________________________________________________________________________________
MEDICATIONS BEING TAKEN:
Please list ALL medication (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if prescription drug), the name of the medication, the dosage, and the frequency of administration.
____ This person takes NO medications on a routine basis
____ This person takes medications as follows:
Medication #1 _________________Dosage __________Specify time taken__________
Reason for taking ____________________________________________________
Medication #2 _________________Dosage __________Specify time taken__________
Reason for taking ____________________________________________________
Medication #3 _________________Dosage __________Specify time taken__________
Reason for taking ____________________________________________________
Attach additional pages for more medications.
Identify any medications taken during the school year that participant does/may not take during the summer: _________________________________________________________________
General Questions (Explain yes answers below.)
Has or does the participant: YES NO
1. Had any recent injury, illness or infections disease? ___ ___ -- _____________________________
2. Have a chronic or recurring illness/condition? ___ ___ -- _____________________________
3. Ever been hospitalized?
___ ___ -- _____________________________
4. Ever had surgery?
___ ___ -- _____________________________
5. Have frequent headaches?
.. ___ ___ -- _____________________________
6. Ever had head injury?
. ___ ___ -- _____________________________
7. Ever been knocked unconscious?
___ ___ -- _____________________________
8. Wear glasses, contacts or protective eyewear? ___ ___ -- _____________________________
9. Ever had frequent ear infections?
.. ___ ___ -- _____________________________
10.Ever passed out during or after exercise?
. ___ ___ -- _____________________________
11.Ever been dizzy during or after exercise?
. ___ ___ -- _____________________________
12.Ever had seizures?
___ ___ -- _____________________________
13.Ever had chest pain during or after exercise? ___ ___ -- _____________________________
14.Ever had high blood pressure?
___ ___ -- _____________________________
15.Ever been diagnosed with a heart murmur? ___ ___ -- _____________________________
16.Ever had back problems?
.. ___ ___ -- _____________________________
17.Ever had problems with joints (ie. Knees/ankles) ___ ___ -- _____________________________
18.Have an orthodontic appliance? If so, worn when? ___ ___ -- _____________________________
19.Have any skin problems? (rash, itching, acne
) ___ ___ -- ____________________________
20.Have diabetes?
___ ___ -- ____________________________
21.Have asthma?
. ___ ___ -- ____________________________
22.Had mononucleosis in the past 12 months?
. ___ ___ -- ____________________________
23.Had problems with diarrhea/constipation?
___ ___ -- ____________________________
24.Have problems with sleepwalking?
.. ___ ___ -- ____________________________
25. Have an abnormal menstrual history?
. ___ ___ -- _____________________________
26.Ever had an eating disorder?
. ___ ___ -- _____________________________
27.Ever had emotional difficulties for which
professional help was sought?
. ___ ___ -- _____________________________
Which of the following has the participant had?
___ Measles ___ Chicken pox ___ German measles
___ Mumps ___ Hepatitis A / B / C
___ TB Mantoux Test / Date of last test _______________ Results ___postitive ___ negative
Please give all dates (Month/Year) of immunization for:
DTP _____ _____ _____ _____ _____ _____ _____
Tetnus _____ _____ _____ _____ _____ _____ _____
Polio _____ _____ _____ _____ _____
MMR _____ _____ or Measles (only) _____ _____ Mumps (only) _____ _____
Haemophilus influenza B _____ _____ _____ _____ Rubella (only) _____ _____
Hepatitis B _____ _____ _____ Varicella (pox) _____ _____
Use this space to provide any additional information about the participant's behavior and physical, emotional, or mental health about which the camp should be aware.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Name of family physician_____________________________________Phone_______________________
Address _______________________________________________________________________________
Street City State Zip
Name of family dentist/orthodontist _____________________________ Phone ______________________
Address _______________________________________________________________________________
HEALTH CARE RECOMMENDATION BY LICENSED MEDICAL PERSONNEL
I examined this individual on _________________(within 24 months of camp attendance.)
BP _______________ Weight ________________ Height ____ft. ___ in.
In my opinion, the above applicant ____is / ____ is not able to participate in an active camp program.
The applicant is under the care of a physician for the following conditions:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Recommendations and Restrictions at Camp
Treatment to be continued at camp
____________________________________________________________________________________________________________________________________________________________________________
Medications to be administered at camp (name, dosage, frequency)
____________________________________________________________________________________________________________________________________________________________________________
Any medically-prescribed meal plan or dietary restrictions
____________________________________________________________________________________________________________________________________________________________________________
Known allergies
____________________________________________________________________________________________________________________________________________________________________________
Description of any limitation or restriction on camp activities
____________________________________________________________________________________________________________________________________________________________________________
Additional information for health care staff at the camp
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature of Licensed Medical Personnel ___________________________________________________
Printed ____________________________________ Title _______________________________________
Address _______________________________________________________________________________
Phone ______________________________________________________Date_______________________
For Camp Use only
Screening Record
Date screened ______________________________________________ Time _______________AM / PM
Meds received ____________________________________________________________________________________________________________________________________________________________________________
Updates/additions to health history noted: ____ Yes ____ No ____ None required
Current health needs identified ____________________________________________________________________________________________________________________________________________________________________________
Observational notes ____________________________________________________________________________________________________________________________________________________________________________
Screened by _______________________________________________