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Camper medical form page

23970 North Elm Road, Lincolnshire, Illinois 60069 (847) 634-3168 Fax 634-8262 CAMPER HEALTH HISTORY/MEDICAL EXAM FORM
To be completed by parent/guardian and pediatrician and must be on file at camp prior to first day.
Section A – To be completed by parent/guardian
Name_____________________________________________ Birth Date____/____/____ Home Address_______________________________________________________________________________ General Questions
1. Had any recent injury, il ness, or infectious disease? 15. Ever had back problems? .………………. 2. Have a chronic or recurring illness/condition? . 17. Require an orthodontic appliance? ……… 18. Have any skin problems (e.g. itching, rash 7. Ever been knocked unconscious? .…………… 8. Wear glasses, contacts or protective eye wear? …. 21. Had mononucleosis in the past 12 month? 9. Ever had frequent ear infections? …………………… 22. Had problems with diarrhea/ constipation? 10. Ever passed out or became dizzy from exercise? … 11. Ever had seizures? ……………………………………. 12. Ever had heart trouble? ………………………….…. 13. Ever been diagnosed with a heart murmur? …….…. 26. Ever had emotional difficulties for which 14. Ever been diagnosed with a blood disorder? ………. Please explain any “yes” answers, noting the number of the question and any other pertinent information?
_______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ I authorize Tamarak Day Camp medical personnel to give the following over-the-counter medication(s) to my child
as needed. Notification wil be provided if dispensed.
Parent Guardian Authorizations: This health history is correct and complete as far as I know and the person
herein described has permission to engage in al camp activities except as noted.
Signed___________________________ Printed ____________________________ Date _______________
Section B – To be completed by physician (including back side)

Immunizations
are current to date according to the Illinois Admin. Code no. 665?
Comments___________________________________________________________________________________ ____________________________________________________________________________________________ TAMARAK DAY CAMP
23970 North Elm, Lincolnshire, Il inois 60069, (847) 634-3168 Fax (847)634-8262 Health Care Recommendations by Licensed Medical Personnel
Participant Name_____________________________________________ Birth Date____/____/____
I have examined the above camp participant. Date of examination ____/____/____ BP_______ Weight ______ Height _______ is not able to participate in an active camp program.
The applicant is under the care of a physician for the following conditions ______________________________________
______________________________________________________________________________________________________ Current treatment at the time of this report includes__________________________________________________________
______________________________________________________________________________________________________

Recommendations and Restrictions at camp
Treatment to be continued at camp__________________________________________________________________________
______________________________________________________________________________________________________ Any medical-prescribed meal plan or dietary restrictions _________________________________________________________ ______________________________________________________________________________________________________ Description of any limitation or restriction on camp activities_______________________________________________________ ______________________________________________________________________________________________________ Additional information for health care staff at the camp___________________________________________________________ ______________________________________________________________________________________________________

Food Allergies:

No If, Yes, a “Food Allergy Action Plan” must be completed prior to camp.
Medication Allergies (list)________________________________________________________________________________
______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Other Allergies (list) – insect stings, hay fever, asthma, etc. Include medications provided at camp office.
______________________________________________________________________________________________________ ______________________________________________________________________________________________________

This person takes medication on a routine basis

Medication #1________________________________ Dosage & Times day________________________________________ Reason for taking _______________________________________________________________________________________ Medication #2________________________________ Dosage & Times day________________________________________ Reason for taking _______________________________________________________________________________________ Attach additional pages for more medications.
Identify any medications taken during the school year the participant does/may not take during the summer
______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Additional information about the participants behavior, physical, emotional, or mental health about which the camp
should be aware.
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Signature of Licensed
Medical Personnel
_______________________________ Printed ____________________________ Date _______________
Address_______________________________________________________________ Phone _________________________

Source: http://www.tamarakdaycamp.com/pdfs/Camper_Medical_Form.pdf

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