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Sullivanhills.org

HEALTH HISTORY FORM
FOR OFFICE
FOR CHILDREN, YOUTH AND ADULTS
PARTICIPATING IN NLOM CAMP PROGRAMS
DUE 2 WEEKS PRIOR TO CAMP
PLEASE PRINT OR TYPE
The following information must be filled out by the parent/legal guardian or adult camper or staff member. The intent of this information is to provide camp health care personnel the background to provide appropriate care. We suggest you keep a copy of the completed form for your records. Any changes to this form should be provided to camp health personnel upon participant’s arrival in camp. It is the responsibility of the parent/guardian or adult to provide complete information to the camp.
Name _______________________________________________________________________________ Date of birth _______________ ❏ Male ❏ Female Age _______Grade completed prior to camp _______ Parent/Guardian (or spouse) _____________________________________________________________ Address _________________________________________________________________________ City/State/Zip _______________________________________e-mail address__________________ Home Phone ( )___________Daytime Phone ( )_________Cell Phone ( )____________ 1. __________________________ ( ) ____________________( ) _______________________ 2. __________________________ ( ) ____________________( ) _______________________ 3. __________________________ ( ) ____________________( ) _______________________ WE MUST HAVE 3 DIFFERENT CONTACTS WITH DAY AND EVENING PHONE NUMBERS
INSURANCE INFORMATION
Is the participant covered by family medical/hospitalization insurance? ___Yes ___No If so, list: Carrier __________________ Policy # _______________Group # ______________________ Insurance Carrier Address _______________________________________________________________ Name of insured parent ____________________________________DOB _________________________ Name of insured parent’s employer ________________________________________________________ Is this an HMO? __________Is this a Primary Provider (PPO)? ________ Is there a hospital in Lincoln/Omaha area that your insurance requires us to use? ___________________ Dentist/Orthodontist ___________________________ Phone ___________________________________ Family Physician _____________________________ Phone ___________________________________ Date of last physical exam ______________________ In case of camp-related accident or il ness, NLOM carries insurance to cover medical costs that the camper’s own insurance does not cover. We do not cover pre-existing conditions.
HAS/DOES THE PARTICIPANT:
2. Have a chronic or recurring illness/condition? . ❏ ❏ 17. Wear glasses, contacts, protective eye wear? .❏ ❏ 6. Ever had frequent ear infections? . ❏ ❏ 8. Ever had chest pain during or after exercise or ever 21. Had mononucleosis in the past 12 months? .❏ ❏ passed out during or after exercise? . ❏ ❏ 22. Had problems with diarrhea/constipation? .❏ ❏ 9. Ever had high blood pressure? . ❏ ❏ 23. Had problems with sleepwalking? .❏ ❏ 10. Ever been diagnosed with a heart murmur? . ❏ ❏ 24. Have a history of bed wetting? .❏ ❏ 12. Ever had problems with joints (e.g. knees, ankles)? ❏ ❏ 13. Have learning disabilities . ❏ ❏ 26. Ever had an eating disorder? .❏ ❏ 14. Have behavior concerns such as ADD/ADHD . ❏ ❏ 27. Ever had emotional difficulties for which professional help was sought? .❏ ❏ Please explain any “yes” answers, noting the corresponding question number _______________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ To help make your child’s visit to camp successful, it is vital that we are aware of any unique needs or special concerns they may have. Attach a separate sheet explaining special learning considerations, family circumstances, relevant experi- ences, activity restrictions or anything that will help us better prepare for your child’s upcoming camp visit. In the event of an emergency or serious illness/injury, parents will be notified by camp staff. If the participant has been under the care of a physician or counselor within the past 12
months or if there are any activity restrictions, attach a signed statement from your physi-
cian/counselor indicating restrictions, concerns and pertinent recommendations.
Which of the following has the participant had? Date of most recent tetanus immunization___________________ Describe reaction and management of the reaction.
____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ Other Allergies (list) - include insect stings, hay fever, animal dander, etc.
____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ ____________________________________________ ____________________________________________________ ❏ no red meat ❏ no poultry ❏ no eggs ❏ no dairy products ❏ other (describe) ___________________________________________ __________________________________________________________________________________________________________________ List ALL medications (including over-the-counter or nonprescription drugs such as aspirin) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician, the name of the medication, the dosage and the
frequency of administration. All medications must be turned in to the camp health care staff at the time of check-in.
Med #1 __________________________ Dosage _________________________ Specific times taken each day _____________________________ Reason for taking _______________________________________________________________________________________________________ Med #2 __________________________ Dosage _________________________ Specific times taken each day _____________________________ Reason for taking _______________________________________________________________________________________________________ Med #3 __________________________ Dosage _________________________ Specific times taken each day _____________________________ Reason for taking _______________________________________________________________________________________________________ (Attach an additional sheet if necessary) I (parent/guardian) give permission for NLOM to administer over-the-counter medications if the health care staff deems necessary. I understand the NLOM Health Care staff will administer medications per instructions in the NLOM Health Care Plan, which is approved by a physician, that dosages will be administered according to the directions on the bottle unless a physician directs otherwise, and that health history forms will be reviewed for allergies and parental recommendations prior to administration of over-the-counter medications.
Signature of Parent/Legal Guardian or adult camper/staff member Examples of over-the-counter medications administered by NLOM: Tylenol, Pepto Bismol, Ibuprofen, Immodium AD, Sudafed, Benadryl, Antacid/Anti-gas Liquid, Hydrocortisone Cream, Cough Drops, Tums, Tavist-D, Cough Syrup. IMPORTANT: THIS BOX MUST BE COMPLETED AND SIGNED FOR ATTENDANCE
This health history is correct so far as I know, and the person herein described has permission to engage in all pre- scribed camp activities except as noted. AUTHORIZATION FOR TREATMENT: I hereby give permission to the medi- cal personnel selected by Nebraska Lutheran Outdoor Ministries (NLOM) to order X-rays, routine tests, treatment and necessary transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by NLOM to secure and administer treatment, including hospitalization, for the person as named above. The completed form may be photocopied for trips out of camp.
Signature of Parent/Legal Guardian or adult camper/staff member With my parents/guardian, I have completed the above information and will assume the responsibility for my medica- tions and for restricting any activities agreed upon and listed above. I will exercise good judgment in regard to my own health, safety and well-being while at camp.

Source: http://www.sullivanhills.org/attachments/article/61/healthhistoryform%202013.pdf

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