Staff Medical Form and Health History
Note: The information in this document will be kept in your confidential file for emergency purposes only.
Identifying Information
Name
*
First Name
Last Name
Gender
*
Date
*
-
Month
-
Day
Year
Date Picker Icon
Age as of Camp Dates:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Emergency Contact: (This should be someone you are comfortable with making medical decisions for you in case of emergency.)
*
First Name
Last Name
Emergency Contact's relationship to you:
*
City/State of Emergency Contact:
*
Emergency Contact's Phone Number(s):
*
Physician and Insurance Information
Primary Physician:
*
Clinic where Physician works:
*
Clinic Phone Number:
*
Insurance Company:
*
Insurance Policy Number:
*
Epilepsy and/or Seizure History
Epilepsy or any history of seizure disorder?
*
Yes
No
If yes, list seizure type:
Date of last seizure:
Controlled by Medication?
Yes
No
Allergies and Dietary Restrictions
Check all that apply:
*
No Known Allergies
Latex Allergies
Epi Pen Required
Allergies to Medications
Allergies to Food
Seasonal or Environmental Allergies
Allergies to Insect Bites or Stings
Please provide details on any allergies checked:
Please describe any special dietary needs including allergies and foods you avoid for medical or religious reasons:
*
Are all vaccines up to date?
*
Yes
No
Covid-19 Vaccine?
*
Yes
No
Date of last Tetanus vaccine:
*
Well Being
Have you ever been diagnosed with or experienced any of the following:
*
Depression
Anxiety
OCD
Bipolar Disorder
Panic Attacks
BPD/Personality Disorders
ADHD
Eating Disorder
PTSD
Sleep Problems
Self-Harm
Suicidal Feelings
None
Other
How can we best support you through these concerns while you are at Camp Grassick?
Please describe information relating to mental health status, including, but not limited to: self-harm, hospitalization, participation in therapeutic programs, increased depression or anxiety, suicidal ideation, or other concerns:
*
Medications
Please list medications you will be taking while at Camp Grassick or attach a list:(Please include dosage)
*
example: Lexapro 10mg 1x/daily
Note: If you use medical marijuana, a copy of your medical card must be provided to the director.
Are there any OTC medications that you should NOT take?
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Health History
Please list any recent surgeries, infections or serious illnesses:
Have you ever been diagnosed with or experienced any of the following conditions? Check all that apply.
*
Arthritis
Asthma
Bleeding/Clotting Disorders
Concussions
Diabetes
Frequent Ear Infections
Hepatitis
Frequent Headaches/Migraines
Frequent Sinus Infections
Hearing Impairment
Heart Defect/Disease
High Blood Pressure
Heat Illness
Mobility Concerns
Mononucleosis
Loss of Consciousness/Fainting
Pneumonia
Sleepwalking
Stroke/TIA
Vision Impairment
None
Please elaborate on any of the checked boxes if necessary.
Are there any other specific concerns or pertinent information concerning your health that the administration of Elks Camp Grassick should be aware of or that may affect your ability to do the job you were hired for?
*
Print
Save
Submit
Should be Empty: