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2008 SUMMER HEALTH HISTORY FOR ROCKY RIVER RANCH We use this information to: (a) Brief kitchen staff about diet needs; (b) Educate counseling staff about camper needs; and (c) Provide healthcare staff with background about your child. Receiving adequate information by May 1, 2007 is crucial to our ability to provide a supportive environment.
Health History: To be completed and signed by parent. Return this form by May 1 (immediately for late registrations). Keep a copy for your records and to record changes in your child’s health status. Notify Rocky River in writing if there are changes.
Allergies (Check those that apply to your daughter.) ❒ My daughter has no known allergies.
❒ My daughter has an allergy to the following food(s): Describe the reaction if this food is eaten and what is done to manage it: ❒ My daughter is allergic to the following medication(s): Describe the reaction and how it has been managed: ❒ My daughter is allergic to the following substance(s): Describe the reaction and what is done to manage it (attach additional information if needed): Diet (Check those that apply to your daughter. Our kitchens prepare a variety of food, and while we can work with some medically-prescribed diets, we cannot cater to individual food preferences. Please call if you have questions about diet management.) ❒ My daughter eats a regular, varied diet.
❒ My daughter is a vegetarian.
❒ My daughter is lactose-intolerant. NOTE: Our expectation is that your daughter self-manages using products such aslactaid and/or brings lactose-free products (such as milk).
Immunization History (Provide the month and year for each immunization. Starred [*] immunizations must be current.) HepB: Hepatitis BHib: H.infl uenzae, type bVaricella (Chicken Pox) Chronic Concerns Check all that pertain to your daughter and provide information about supportive health care.
❒ My daughter has no chronic health concerns and is capable of full participation in this program.
❒ My daughter has the following health concern(s): Provide information about supportive health care needed for each checked item: *Call (800) 863-2267 to request an additional form if your child has asthma. Complete the appropriate additional form(s) and attach it to this health history form. You may also download the form at www.rockyriverranch.com.
Medication Provide complete information. Bring enough medication to last the entire session. ALL medica-tions must be in pharmacy containers and appropriately labeled (see Pointers to Parents). Campers should be taking the same medication at the same dose for at least three months prior to arrival; email the Directors at info@rockyriverranch.com or call 1-800-863-2267 with any changes.
❒ My daughter does not take any medication.
❒ My daughter takes daily medication (include vitamins) as follows (attach more information if needed): These medications, stocked in our Health Center, are used to manage illness or injury and dispensed as directed by our medical protocols. CROSS OUT those which your daughter should not be given:Acetaminophen (Tylenol) General History Check “Yes” or “No” for each statement.
My daughter has had chicken pox or is immunized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ NoMy daughter has been free of mononucleosis for the past 12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ NoMy daughter’s hearing is within normal ranges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ NoMy daughter has appropriate vision or uses corrective lens to remedy vision . . . . . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ NoWhat should we do if there is loss or damage? My daughter has dental equipment (braces, retainer, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ NoWhat should we do if there is loss or damage? My daughter is free of illness, injury, or surgery which would aff ect program participation . . . . . . . . . . . ❒ Yes ❒ NoMy daughter knows about menstruation and/or has a normal menstrual history . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ No Mental, Emotional, and Social Health Check “Yes” or “No” for each statement.
1. My daughter has been diagnosed with Attention Defi cit Disorder (ADD) or AD/HD . . . . . . . . . . . . . . . . ❒ Yes ❒ No2. My daughter has been diagnosed with an eating disorder (ex. Bulimia, anorexia) . . . . . . . . . . . . . . . . . ❒ Yes ❒ No3. My daughter has a psychiatric diagnosis such as depression, OCD, panic/anxiety disorder . . . . . . . . . ❒ Yes ❒ No 4. My daughter has an emotional health concern (specify: 5. During the past academic year, my daughter has seen or is currently seeing a professional to address mental/emotional concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❒ Yes ❒ No If “yes” was the answer to any of the fi ve statements above, attach a statement from your child’s professional (e.g. physician, psychiatric) that addresses the following three elements: (a) Describes the concern and your daughter’s management plan (including medications) while in our program; (b) Describes the behaviors which will indicate to our staff that your daughter needs professional referral. And; (c) Provides a recommendation for your daughter’s participation at Rocky River Ranch.
6. My daughter has been in countries other than the United States in the past nine months . . . . . . . . . ❒ Yes ❒ No If “yes”, list the countries and the length of time spent in them.
Provide additional information about your child’s health, if needed, by attaching a written page to this form.
What have we forgotten to ask? Provide additional information about your child’s health which may have been neglected on this form or additional explanations for any question already on this form. We are particularly interested in information which has impact upon your child’s ability to fully participate in our program.
Billing information for Health Care Parents/guardians are fi nancially responsible for health care given by an out-of-camp provider. To whom should this provider route charges for your daughter’s health care? Include a copy of an insurance card if appropriate. Copy both sides of the card so addresses and telephone numbers are read-able. Please arrange pre-authorization for your child’s medical care if your insurance requires this.
Parent Contact Information We will call in an emergency or if we have questions about your daughter. Pro-vide contact information for other people who know your child and with whom we can consult if we cannot reach you. We assume you have spoken with these individuals and they are willing to assist should the need arise.
Parent/Guardian Authorization for Health Care This health history is correct, and the person described has permission to participate in all Rocky River activities except as noted by me and/or the examining physician. I give permission to the physician selected by Rocky River Ranch to order X-rays, routine tests, and treatment for the health care of my daughter. 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 the child. This form may be photocopied. Rocky River Ranch has permission to obtain a copy of my daughter’s health record from the providers who treat my child. I understand that information about my child’s health will be shared on a “need to know” basis with other Rocky River staff .
Send this Health Form to our offi ce NOW. Remember to keep a copy to record changes in your daughter’s health status. We are interested in providing good health care to your daughter. Please have your physician complete the enclosed Medical Recommendation and return it to our offi ce no later than May 1, 2008.
Questions? Contact us at 1-800-863-2267 or info@rockyriverranch.com.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~For offi ce use only~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EXIT NOTE Check one of the following:❒ Left Rocky River this day with no reported illness or injury symptoms. ❒ Left Rocky River this day with the following problem/concern: This problem was referred to (name of responsible person)

Source: http://www.rockyriverranch.com/camp/pdf/HealthHistory08.pdf