Camper Health History - PDF Templates

Medical Information and Emergency Contact

January 24, 2019

Camper Name

Kubra Sarıgoz

EMERGENCY CONTACT INFORMATION

Address

Las Vegas, Nevada

Full Name

John Denver

Relationship to Child

Father

Secondary Phone Number

(111) 111-1111

Primary Phone Number

(111) 111-1111

Address

Las Vegas, Nevada

Full Name

Nelly Denver

Relationship to Child

Mother

Secondary Phone Number

(222) 222-2222

Primary Phone Number

(222) 222-2222

MEDICAL INFORMATION

Name of Physician or Clinic/Hospital

Patrick Nielson Hospital

Phone Number

(111111) 111-1111

Is the Camp up-to-date on all immunizations?

Yes

Address

John Doe Street

Las Vegas, Nevada, 45212

Date of Last Tetanus or Diphtheria, Tetanus, Pertussis (DTaP) Vaccine?

Thursday, January 24, 2019

Does your child have any food, medication or environmental allergies?

Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?

Does your child have a special health or medical condition?

Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?

Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?

Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?

Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?

List any history of hospitalization, outpatient surgery, or previous health concerns that would be needed to assist the staff or medical personnel in an emergency situation.

N/A

List any additional information about your child that would be useful for staff to know, such as fears, eating or sleeping habits, or special routines. This information should not be medical or health related, as that information should be included in the previous questions.

N/A

ADDITIONAL MEDICATION

Food supplement

Modified diet

Exact dosage

test

Name of medication

test

To be administered at the following times

test

If your child's medication meets any of these criteria:

A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
It is a sample medication without a prescription label; or
The nonprescription medication is to be given longer than three consecutive days within a fourteen day period or is a topical product or lotion that is being used for a skin ailment and is to be given no longer than fourteen consecutive days; or
The child is on a modified diet (an entire food group is eliminated); or
The medication contains codeine or aspirin.

***The topical product or lotion and the physician's instructions exceed the manufacturer's instructions or use