Health History

Published on July 2016 | Categories: Documents | Downloads: 44 | Comments: 0 | Views: 455
of 3
Download PDF   Embed   Report

Comments

Content

Name: Lastname FirstName Age: Age Birth date: Birthdate Grade: Grade

Session Gender: Female

Custodial Parent #1 – ParentName1 Parent1Phone Parent1Address Custodial Parent #2/Emergency Contact – ParentName2 Parent2Phone Parent2Address Emergency Contact: EmergencyContact EmergencyContactRelation EmergencyContactPhone INSURANCE – Insurance? Carrier or Plan: InsuranceCarrier ALLERGIES Medication Allergy #1 : Medication Allergy #2 Medication Allergy #3 Food Allergy #1: Food Allergy #2: Food Allergy #3: Other Allergy: Other Allergy: Other Allergy: MEDICATIONS This Person takes no medication: NoMeds This Person takes medications: Meds Med #1: Med #2: Med #3: Med #4: Dosage: Dosage: Dosage: Dosage: Time of Day: Time of Day: Time of Day: Time of Day: Reason: Reason: Reason: Reason: Reaction: Reaction: Reaction Reaction: Reaction #2: Reaction: Reaction: Reaction: Reaction: Group # InsuranceGroup

RESTRICTIONS Dietary: Does not eat nuts: Other: 0 Explain Restrictions: GENERAL QUESTIONS Recent injury, illness or infections disease: Chronic or recurring illness/condition: Had Surgery: Frequent Headaches: Head Injury: Knocked Unconscious: No No No No No No Back Problems: Problems with Joints (knees, ankles) No No Describe:

Orthodontic Appliance being brought to camp : No Skin Problems (itching, rash, acne) Diabetes: Asthma: Mono in the past 12 months: Diarrhea/constipation: Sleep Walking: Abnormal Menstrual History: Bedwetting History: Eating Disorder: No No No No No No No No No

Weare Glasses, Contacts or Protective Eyewear: Yes Frequent Ear Infections: Passed out during or after exercise: Dizzy during or after Exercise: Seizure: Chest Pain during or after exercise: High Blood Pressure: Diagnosed with a heart murmur: Explain: No No No No No No No

Emotional Difficulties for which professional help was sought? No

This participant has had the following: Shots: TB Mantoux Test: Result of TB Test: DTP: 1/00 3/00 5/00 2/01 12/04

TD(Tetanus/Diphteria): Tetanus: Polio: 1/00 MMR: 11/00 Measles: Mumps: Rubella: Haemphilius influenza B: 1/00 3/00 Hepatitis B: 5/00 Varicella: 11/00 8/00 2/01 5/00 2/01 3/00 12/04 11/00 12/04

Additional Information: OTC Meds ok?: Yes If not, Please List:

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close