Microsoft word - medical form 2013.doc

MEDICAL INFORMATION FOR NATURE CAMP—2013

Please fill out all four pages and return within four weeks of the start of camper’s session to

If possible, please arrange for camper to have examination by physician no more than four weeks prior to the start
of his or her session so that medical information will be as up to date as possible. The American Camp Association
recommends that all campers undergo a physical examination within 12 months of start of camp session.
PARENTS / GUARDIANS
Please fill out this form completely before presenting to physician. Use additional sheet if necessary. Camper’s Name: ______________________________ Session: _________________ □ Male □ Female Address: _____________________________________ City: ____________________ State: ______ Zip: ________ Social Security # ______________________________ Date of Birth: _____________ Age on arrival at Camp: _____ Medical Insurance Information:
This camper is covered by family medical/hospital insurance: □ Yes

Please include a copy of your insurance card if appropriate; copy both sides of the card so that information is readable.
Insurance Company: __________________________________ Policy Number: _______________________________
Subscriber: _________________________________________ Insurance Company Phone # (______) _____________
Camper’s Medical History:
List any medications or pills to be taken regularly at camp and directions for their use:
List any other medications taken at home:


Drug allergies:
If yes, please list drug and reaction (e.g., amoxicillin caused rash). If yes, please list (e.g., asthma, diabetes). If camper has ever been admitted to hospital overnight, please list year and diagnosis. List any past surgical procedures and significant orthopedic injuries (fractures or bad sprains). Does the camper need corrective If yes, _____ glasses and or ______contacts Does the camper have any allergies to insect bites, stings, spiders or food? If yes, note date, reaction and treatment. NOTE: Nature Camp will strive to accommodate individual dietary restrictions, but if camper has food allergies, please consider bringing alternative food items to leave with the cooks and discussing particular needs with them at the beginning of the session. Has the camper ever been seen by a psychiatrist or psychologist? If yes, for what? Does the camper have any learning disabilities of which the instructional staff should be aware and which might affect his or her ability to complete written class assignments? If yes, please explain and note any helpful assistance which the staff could provide. Has camper ever: received a transfusion of blood products? been thought to have an eating disorder? Is there any family history of: (If yes, please explain.) heart disease at a young age (<30 years)? Age at onset of menstrual periods: _____ Has camper ever missed more than two periods?
Parent/Guardian please note:

1.
Nature Camp maintains a supply of some common, over-the-counter medications, as well as other first aid items available for the camper’s health. (See back page.) Any medication (prescription or over-the-counter) brought by camper must be registered with the camp’s Infirmary Staff at check in, so that we may monitor treatment. (We must be certain that campers are not treating themselves or others without our knowledge.) In an effort to reduce infectious outbreaks at camp, please notify Nature Camp if your child has any illness in the week prior to session start (such as chicken pox, vomiting or diarrhea, bad head or chest cold). You may be requested to talk to Infirmary Staff on arrival at camp if:  camper has medication to be checked in.  there is a need for further medical information or clarification.  this medical form is incomplete.
Please list name and telephone number of camper’s regular medical providers.
_______________________________ Telephone # (______)___________________ _______________________________ Telephone # (______)___________________ _______________________________ Telephone # (______)___________________ Immunization History: Provide the month and year for each immunization. Immunizations marked with an asterisk (*) must be
current. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this
form.
Most Recent Dose
Immunization
Month/Year
Month/Year
Month/Year
Month/Year
Month/Year
Month/Year
Diptheria, tetanus, pertussis * (DTaP or TdaP) (chicken pox) Date: Meningococcal meningitis (MCV4)
If camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from
not being fully immunized.
Signature
Parent / Guardian : ________________________________________________ Date: _______________ to Camper: _____________________ PHYSICIAN
Please review prior information for accuracy and fill out information below. Patient’s Vital Signs: Weight _____ lbs Vision (with or without corrective lenses): Please describe any heart murmur or vascular bruit. List any abnormalities on physical exam. Activities at Nature Camp can be strenuous. Are there any restrictions on activity or specific precautions which should be noted? Name of licensed provider (print): ______________________________ Signature: _______________________ Title: ____________ Office Address: __________________________________________________________________________________ Telephone # ( _____ ) ______________________________ Date of exam: _________________________________ The following non-prescription medications may be stocked in the Nature Camp infirmary and are used as needed to
manage illness and injury. Please cross out those which the camper should not be given.
Acetaminophen (Tylenol)
Ibuprofen (Advil)
Naproxen sodium (Aleve)
Tylenol liquid cold product
Sudafed, etc. (does not contain pseudoephedrine)
Dayquil
Nyquil
Ricola cough drops
Tavist-D
Benadryl
PARENT / GUARDIAN
PLEASE INITIAL ________
Cepacol throat spray Epi-pens Excedrin (contains acetaminophen, aspirin, caffeine) Advil cold/sinus Robitussen expectorant, cough suppressant, nasal decongestant Sterile saline solution Hydrogen peroxide Arniflora gel, Califlora gel SSSting-stop Rhuligel Calamine lotion Medsporin Alcohol swabs Povidine – iodine solution (Betadine) Non-powder, vinyl gloves (non-latex) EMERGENCY CONTACT INFORMATION – Please provide telephone numbers for individuals to be reached in the event of an emergency. Please indicate the type (e.g., home, work, cell, pager) for each number.
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 physician selected by Nature 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 Nature Camp staff. I give permission to photocopy this form. In addition, Nature
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.
Name of Custodial Parent / Guardian (print): __________________________________
Relationship to Camper: ___________________ Signature for emergency treatment: ______________________________________ Signature for non-acute treatment: ______________________________________

Source: http://naturecamp.net/wp-content/uploads/2013/05/medical-form-2013.pdf