Medical and Health History

Medical and Health History

Required for campers at all sessions at Elks Camp Grassick.
Please Note: All individuals accepted for attendance at Elks Camp Grassick must receive a physical examination by a doctor before coming to camp. The Medical Physical Information form should be filled out completely by a physician and sent to camp prior to the individual’s arrival at camp if possible. Attachment of the physical examination report would be beneficial during the screening and selection process, but if the cost of such a physical examination is a concern or if an individual’s physical is typically scheduled closer to camp times, this form does not need to be filled out until after you know that this person has been accepted and it can be sent later or brought with the individual at check in.

Lice Check: No lice check form will be required. If the individual or someone in the household has been exposed to lice prior to attending camp, please inform staff immediately. Lice checks may be done at check in. Thank you!
Medical Form/Health History

To be completed by the parent, guardian, or caregiver. This portion must be completed and submitted to Camp Grassick with the application.
Name of Camper*

First Name Last Name
Gender*

MaleFemale
Birthdate*

MonthDay Year
Age*
Height*
Weight*
Primary Medical Diagnosis*
Secondary Medical Diagnosis
Individual's Physician*
Clinic where Physician works*
Clinic Phone Number*
Please enter a valid phone number.
Insurance Company
Insurance Number
Medical Assistance Number (If Applicable)
Epilepsy and/or Seizure History
Epilepsy or any history of seizure disorder?*

YesNo
Seizure Type
Date of last seizure
Controlled by medication

YesNo
Any other pertinent information about this individual's seizure disorder?
Allergies & Dietary Restrictions
Check all that apply:*

No Known AllergiesLatex AllergiesEpi Pen RequiredAllergies to MedicationsAllergies to FoodSeasonal or Environmental AllergiesAllergies to Insect Bites or Stings
Please provide details on any allergies checked.
Please describe any special dietary needs.*
Vaccines
Are all vaccines up to date?*

YesNo
Covid-19 Vaccine?*

YesNo
Date of Last Tetanus vaccine:*
Mental Health
Depression (diagnosed)*

YesNo
Anxiety (diagnosed)*

YesNo
Self-injurious behavior during the past year?*

YesNo
Aggressive behavior during the past year?*

YesNo
Describe any mental health concerns. Please explain if you answered yes to any of the previous 4 questions.
Assistive Devices
Does the individual use any assistive devices? Check all that apply.*

OrthoticsCommunication DeviceC-Pap MachineCrutches or WalkerDenturesGlasses or ContactsG-Tube or J-TubeHearing AidsImplanted DeviceInhalerWheelchairNo Assistive DevicesOther
Medications

Note: Please bring medication to camp in their original containers with legible prescription labels or pre-packaged by a pharmacy. If medications are packed in med planners, please bring a list of medications, dosage and times.
Please list medications this person will be taking while at Camp Grassick or attach a list. Please include medication, time(s) given, dosage, and special instructions.*
Upload a list of medications here if necessary.

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

Cancelof
Please check any medications this person may take if needed while at Camp Grassick:*

Tylenol/AcetaminophenAdvil/IbuprofenBenadrylAllergy MedicationCough DropsCough/Cold medicinePepto Bismol
Is there any OTC medication that this person should NOT take?*
Health History
Please list any recent surgeries, infections, or serious illnesses.*
Has the individual ever been diagnosed with or experienced any of the following conditions? Check all that apply.*

ArthritisAsthmaBedwettingBroken BonesBleeding/clotting disordersChicken PoxConcussionsDiabetesDislocated jointsEpilepsy/Seizure DisorderFrequent Ear InfectionsHepatitisFrequent Headaches/MigrainesFrequent Sinus InfectionsIncontinenceHearing ImpairmentHeart Defect/DiseaseHigh Blood PressureHeat IllnessesMeaslesMononucleosisLoss of Consciousness/FaintingMumpsNightmaresPneumoniaSleepwalkingSpina BifidaStroke/TIAVision ImpairmentNoneOther
Please elaborate on any of the checked boxes if necessary.
Are there any other specific concerns or pertinent information concerning this child's health that the staff of Elks Camp Grassick should be aware of?
This form should be submitted to Camp Grassick with the application. The Medical Physical Exam form can be completed and submitted later or brought with the camper at check in. If you have any questions, please call Camp Grassick at 701-327-4251
Should be Empty:

Medical and Health History

Medical Form/Health History

Epilepsy and/or Seizure History

Allergies & Dietary Restrictions

Vaccines

Mental Health

Assistive Devices

Medications

Health History