Health History Form - YMCA Camp Frank A. Day

Health History FormCamp(s) Attending: _____________Session(s) Attending: ____________Health History Forms must be filled out bya parent/guardian. Please complete pages 1-4. Incomplete or unsigned forms will bereturned to you.Please return the completed health history form and other documentation viaemail:campingservices@westsuburbanymca.org, Fax: 617-321-2267or mail:West Suburban YMCA, Attn: Camping Services Registrar276 Church St, Newton, MA 02458In addition to this completed form, the following must be submitted in order to complete your camper’s health record:Any missing pieces will delay processing. This health history form (including required signature on page 3) Copy of child’s most recent physical exam OR page 4 of this form filled out by a licensed health care provider Certificate of immunizations signed by a licensed health care provider Photocopy of front and back of insurance card Please keep a copy of the completed form for your recordsCamper’s Name: ____________________________________________________________________ Birth Date: ______/______/______Camper’s Physician Name: __________________________________________________ Phone: _______________________________Address: _______________________________________________________________________________________________________Camper’s Dentist/Orthodontist Name: _________________________________________ Phone: ______________________________Address: ________________________________________________________________________________________________________Insurance Information:Is the camper covered by family medical/hospital insurance? NO YES (Please complete the remainder of this section.)Carrier or Plan Name: _________________________________________ Group or Policy Number: _______________________________MEDICAL HISTORYThe following information must be filled in by the parent/guardian. This information is intended to provide camp health carepersonnel with the background to provide appropriate care. Please keep a copy of the completed form for your records. Anychanges to this form should be provided to the camp health personnel upon the camper’s arrival to camp. Complete informationmust be provided so that the camp may be aware of your camper’s needs.If “NONE” please indicate that clearly below—do not leave blank.ALLERGIES List all known.Medication allergies NONE____________________________________Describe reaction and management of the reaction:____________________________________________________________________________________________________________________________Food allergies NONE Describe reaction and management of the reaction:________________________________________________________________________________________________________________________________________________________________Other allergies NONE____________________________________Include insect stings, hay fever, asthma, animal dander, etc.:____________________________________________________________________________________________________________________________RESTRICTIONSExplain any limitations to activity (e.g. what cannot be done at all or what adaptations are necessary for participation): NONE____________________________________________________________________________________________________________________________________________________________________________Camper does not eat: red meat pork poultry seafood eggs dairy product nuts & nut products other:____________________________________________________________________

Camper’s Name: _________________Camp(s) Attending: _______________MEDICATIONSPlease list ALL medications, including over-the-counter or nonprescription drugs taken routinely. Bring enough medication tolast the entire time at camp. Medication must be in the original packaging/bottle that identifies the prescribing physician (if aprescription drug), the name of the medication, the dosage and the frequency of administration. All medications must be givento the camp nurse or health care supervisor on the first day at check-in. NONE As of _____/_____/2012, this person takes the following medications:Identify any medication taken during the school year that the participant does/may not take during the summer: _________________________________________________________________________________________________________________Name of medication Date started Reason for taking it When it is given Amount/dose given How it is givenQUESTIONAIRE□ Breakfast □ Lunch□ Dinner □ Bedtime□ Other: __________________□ Breakfast □ Lunch□ Dinner □ Bedtime□ Other: __________________□ Breakfast □ Lunch□ Dinner □ Bedtime□ Other: __________________Applicable to Camp Frank A. Day and Camp Chickami campers ONLY: The following non-prescription medications arecommonly stocked in the nurse’s office and used on an as needed basis to manage illness and injury. These medications will begiven only by the registered nurse present at camp. Cross out those items the camper should not be given.Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Sudafed/Sudafed PE GuaifenesinChloropheneramine maleate Guaifenesin (Tussin) Dextromethorphan (Tussin) BenadrylGeneric cough drops Chloraseptic (sore throat spray) Lice shampoo/Scabies cream Calamine lotionPepto-Bismol Laxatives for constipation Hydrocortisone 1% cream Calamine lotionTopical antibiotic cream AloeHas/does the camper:1. Had any recent injury, illness or infectiousdisease? ……………………………………….2. Have a chronic or recurring illness/condition?3. Ever been hospitalized?...................................4. Ever had surgery?............................................5. Ever had a head injury?...................................6. Ever been knocked unconscious?....................7. Ever had frequent ear infections?...................8. Ever passed out during or after exercise?.....9. Ever been dizzy during or after exercise?......10. Ever had seizures?........................................11. Ever had chest pains during or after exercise?12. Ever had high blood pressure?.......................13. Ever been diagnosed with a heart murmur?...Yes NoYes No14. Ever had back problems?................................15. Ever had kidney or organ problems?............16. Ever had problems with joints?....................17. Have any skin problems or rashes?...............18. Have diabetes?..............................................19. Have asthma?................................................20. Had mononucleosis in the past 12 months?..21. Had problems with diarrhea/constipation?...22. Have problems with sleepwalking?..............23. Wet the bed in the past 9 months?...........24. Ever had an eating disorder?.........................25. Ever had emotional difficulties for whichprofessional help was sought?.........................26. Have an orthodontic appliance being brought tocamp?........................................................Please explain any “YES” answers, noting the number of the question before the answer, and describe treatment.#__, ______________________________________________________________________________________________________________________________________________________________________#__, ______________________________________________________________________________________________________________________________________________________________________#__, ______________________________________________________________________________________________________________________________________________________________________#__, ______________________________________________________________________________________________________________________________________________________________________

Camper’s Name: _________________Camp(s) Attending: _______________MENTAL, EMOTIONAL AND SOCIAL HEALTHHas the camper:1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?2. Ever been treated for emotional or behavioral difficulties or an eating disorder?3. During the past 12 months, seen a professional to address mental/emotional health concerns?4. Had a significant life event that continues to affect the camper’s life?(history of abuse, death of a loved one, family change, adoption, foster care, new siblings, etc.)Yes NoPlease explain any “Yes” answers here: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please describe any current physical, mental or psychological conditions requiring medication, treatment or specialconsiderations while at camp. ____________________________________________________________________________________________________________________________________________________________________________________Please specify circumstances that you would like to be contacted (i.e. a diabetic who has blood sugar less than 70 or greaterthan 250). _________________________________________________________________________________________________________________________________________________________________________________________________Parent/Guardian AuthorizationThis health history is correct and complete to the best of my knowledge. The person herein described haspermission to engage in all camp activities, except noted. I hereby give permission to the camp to provideroutine health care, administer prescribed and over-the-counter medications and seek emergency medicaltreatment, including ordering x-rays or routine tests. I agree to the release of any records necessary fortreatment, referral, billing or insurance purposes. I understand that I and/or my insurance company areresponsible for the expenses incurred. I give permission to the camp to arrange necessary relatedtransportation for my child. In the event I cannot be reached in an emergency, I hereby give permission tothe physician selected by the camp to secure and administer treatment, including hospitalization, for mychild. This completed form may be photocopied as needed.Signature of parent/guardian______________________________________________________________Printed Name _______________________________________________ Date signed ________________Parents:PLEASE ATTACH THE FOLLOWING TO THIS FORM:Page 4 of this application filled out by your child’s physician, OR A print-out from yourchild’s physician stating general health and ability to attend campCertificate of immunizations obtained from your child’s physicianCopy of the front and back of your current health insurance card*Please note that any missing items will delay processing and may affect your camper’sregistration. These forms must be received prior to the start of your child’s camp session.Thank you for your help in making sure that your camper is safe and well-cared for during the summer! This form provides invaluableinformation that our camp staff uses to make appropriate decisions and to provide medical care, if necessary.

Camper’s Name: _________________Camp(s) Attending: _______________PLEASE NOTE:All campers must submit this page filled out by a licensed physician. It is acceptable to attach a doctor’s form hereand write “see attached” for this page, if you do not have this form with you at the time of your doctor’sappointment.PHYSICAL EXAMINATION BY A LICENSED HEALTH CARE PROVIDERI examined this individual on ____/_____/20____. (Must be dated after 8/31/2010.)BP __________________ Weight _____________________ Height _____________________ Temp _________________In my opinion, this applicant is is not able to participate in an active camp program.The applicant is under the care of a physician for the following condition(s): _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________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 limitations or restrictions on camp activities: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Additional information for health care staff at camp: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature of Licensed Health Care Provider: _______________________________________________________Printed Name & Title ________________________________________________ Today’s Date: _______________Address: _____________________________________________________________________________________Phone: _____________________________________ Emergency Number: ________________________________FOR CAMP USE ONLY:Date screened ___________________________________ Session _________________ Time ______________ am / pmMedication received _____________________________________________________________________________________Updates/additions to the health history noted Yes No None requiredCurrent health needs identified _____________________________________________________________________________Observational notes ____________________________________________________________________________________________________________________________________________________________________________________________Screened by _________________________________________Date _____/______/2012

Check session(s) attending:1___ 2___ 3___ Adv___CAMPER CONFIDENTIAL FORMBoth sides of this form should be completed by the parent.Camper’s Name: ______________________________________ Nickname: ______________________Gender: Female Male Date of Birth: _________________ Age: _____We require 2 emergency contacts in case parents cannot be reached during an emergency. Please list:Emergency Contact #1:________________________________________Relation:___________________Home Phone:___________________ Cell Phone_______________________Emergency Contact #2: ________________________________________Relation:___________________Home Phone:___________________ Cell Phone_______________________Describe your child (i.e. disposition, special interests, strengths, weaknesses). ______________________________________________________________________________________________________________Has your child been away from home for more than one week? Yes No How long? ________________Has your child ever been to camp before? Yes NoWhere? ________________________________ What years? ________________How was the experience? _________________________________________________________Please list any siblings attending camp. ______________________________________________________Describe your child’s eating habits. ______________________________________________________________________________________________________________________________________________Does s/he have any strong dislikes for certain foods? Which ones? ________________________________Has your child ever been treated or hospitalized for an eating disorder?Yes NoIs your child afraid of:The dark? Yes Sometimes No Bugs/spiders? Yes Sometimes NoThunder/lightning? Yes Sometimes No Lakes/swimming? Yes Sometimes NoBeing away from home? Yes Sometimes No Other ________________________________How would you best describe your child’s sleeping habits?Normal Light Sleepwalker Sleeptalker Nightmares Night Terrors

Camper’s Name: ______________________________________Has your child wet the bed in the last 9 months? Yes NoHave there been any recent losses/changes (i.e. a move, friend moving away, pet dying, parent’s job change)?Yes NoExplain: __________________________________________________________Does your child have any illness/physical disabilities that may affect your child’s stay? Yes No____________________________________________________________________________________Has your child been seen by a therapist? Yes NoReason for treatment or therapy: ______________________________________________________________________________________________________Please list all possible side effects of medication that your child is on. ____________________________________________________________________________________________________________________Has your child has been on Ritalin, Zoloft, or any other prescription medication influencing behavior or mood?Yes No Explain:______________________________________________________________________How does your child respond to suggestions/criticism? ______________________________________________________________________________________________________________________________What methods work to motivate your child? _______________________________________________________________________________________________________________________________________What language(s) are spoken at home? ______________________________________________________What level of Red Cross Swimming has your child most recently passed? ____________________________Please list any hobbies or interests that you child has. ________________________________________________________________________________________________________________________________What other specific information would be helpful for the counselor to know about your child?__________________________________________________________________________________________________________________________________________________________________________My signature below certifies that I have read, fully understand and accept the policies in the Family Handbook.I understand that any violation of the rules or policies in the Family Handbook can result in my child beingdismissed from camp without a refund.Parent/Guardian Signature ____________________________________________ Date_______________

Please follow this link to download ourFamily Handbook:http://campfrankaday.org/sites/default/files/uploads/docs/2012CFADFamilyHandbook.pdf