Camp Hope Health History and Examination Form for New and Returning Campers
To be completed and signed by a parent/guardian
Name of camper
*
First Name
Last Name
Camper date of birth
*
-
Month
-
Day
Year
Date
Camper Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Name of Physician
*
First Name
Last Name
Physician Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Physician Phone
*
Please enter a valid phone number.
Does the camper have any medication, food, environmental or other allergies?
*
Yes
No
Allergies
*
Medication
Food
Other
Medication Allergies
*
Food Allergies
*
Other Allergies
*
List any dietary restrictions (if none please put n/a)
*
List any activity restrictions (if none please put n/a)
*
Health History
*
Current
History
Explanation of Current Status
A) Asthma
B) Diabetes
C) Frequent Colds
D) Pneumonia
E) Lung/Breathing Problems
F) Seasonal Allergies/Other
G) Ear Infections
H) Frequent Headaches
I) Serious Skin Problems
J) Gum Problems
K) Dental Problems
L) Hypertension
M) Heart/Circulatory Problems
N) Stomach/Digestive Problems
O) Kidney/Urinary Problems
P) Pica (eats inedible objects)
Q) Hepatitis B Carrier
R) Seizure Disorder***
None of the above
Seizure Information Form - for New and Returning Campers
To be completed and signed by a parent/guardian
Name of Camper
*
First Name
Last Name
Does your camper have a seizure disorder?
*
Yes
No
BY SIGNING BELOW I CONFIRM MY CAMPER DOES NOT HAVE A SEIZURE DISORDER
*
Clear
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Seizure Form
Please fill this out to the best of your knowledge. If anything does not apply, please enter None or N/A.
Events or behaviors just before a seizure begins
*
Time of day seizure typically occurs
*
Length of time for seizure
*
Triggers
*
Seizure Classification
*
When was the last seizure?
*
Description (enter N/A if it does not apply)
*
Mouth
*
Sucking
Chewing
Lip Smacking
Grimacing
N/A
Eyes
*
Staring
Blinking
Rhythmic Movement
N/A
Other symptoms
*
Drooling
Tongue Biting
Dilated Pupils
Urination/soiling
Frothing
Sweating
Flushed
Vomiting
Pale
Goose pimples
N/A
Head and Face
*
Nodding
Jerking
Twitching
N/A
Typical seizure lasts
enter a number
*
minutes.
Does he/she usually have more than one seizure at a time?
*
Yes
No
If yes how many in a row?
*
Post Seizure Behavior
*
Normal
Restless
Sleepy
Confused
Deep sleep
Irritable
Other
On the lines located below, please include any other information that may not have been included on the above checklist or to elaborate on any area:
*
This seizure history is complete and correct as far as I know:
*
Clear
Date
*
-
Month
-
Day
Year
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I permit the Arc of Essex County staff to apply sunscreen to my camper:
*
Yes - apply sunscreen
No - please do not apply sunscreen
This authorization covers the period in which the Camp Hope staff is providing care to the camper.
*
Clear
Please DO NOT administer any sunscreen to camper
*
Clear
Sunscreen Type(s)
*
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Your Email
*
example@example.com
Date
*
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: