Camper Health History

    by JotForm Cloned 58

    Campers don’t want to spend their summer in the nurse’s office. To protect campers’ health and safety, this Camper Health History PDF Template collects information about existing medical conditions, allergies, dietary restrictions, immunizations, medication instructions, and emergency contact numbers. If you’d like to customize the template, you can add more information categories or your camp’s logo using JotForm’s PDF Editor.

    With a Silver or Gold plan, you’ll be able to make this form HIPAA-compliant and keep sensitive health information safer than ever. All submissions will automatically be saved as mobile-friendly PDFs camp staff can instantly download and share. Once downloaded, these PDFs can be accessed on any device regardless of WiFi availability, so you’ll be prepared to handle any medical situation no matter where you are.

    NEW

    Collect your online responses with JotForm and turn them into professional, elegant PDFs automatically.

    Camper Health History
    100%
    Medical Information and Emergency Contact
    January 24, 2019
    Camper Name
    Lanie Welham
    EMERGENCY CONTACT INFORMATION
    Address
    New Haven, Connec
    Full Name
    Clevey Grassi
    Relationship to Child
    Aliqua
    Secondary Phone Number
    (111) 111-1111
    Primary Phone Number
    (111) 111-1111
    Address
    Englewood, Colora
    Full Name
    Lanie Welham
    Relationship to Child
    Aliqua
    Secondary Phone Number
    (222) 222-2222
    Primary Phone Number
    (222) 222-2222
    MEDICAL INFORMATION
    Name of Physician or Clinic/Hospital
    Integer ac leo.
    Phone Number
    (6) 8972598
    Is the Camp up-to-date on all immunizations?
    7/20/2018
    Address
    0 Bunker Hill L
    Norfolk, Virgin, 23520
    Date of Last Tetanus or Diphtheria, Tetanus, Pertussis (DTaP) Vaccine?
    Tuesday, August 28, 1990
    Does your child have any food, medication or environmental allergies?
    No
    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?
    No
    Does your child have a special health or medical condition?
    No
    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?
    No
    Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?
    No
    Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?
    No
    Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?
    No
    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.
    Int
    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.
    Mae
    ADDITIONAL MEDICATION
    Food supplement
    Modified diet
    Exact dosage
    Phas
    Name of medication
    Phas
    To be administered at the following times
    Aliq
    For the following period of time
    Starting: 01/16/2019 Ending: 01/31/2019 Difference: 15 days

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

    1. A physician's instruction is needed for a nonprescription medication (e.g. child is underage or underweight per the label instructions); or
    2. It is a sample medication without a prescription label; or
    3. 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
    4. The child is on a modified diet (an entire food group is eliminated); or
    5. The medication contains codeine or aspirin.

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

     

    Camper Health History

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