PCC Health Form #1

PCC Health Form #1

This form is mandatory for the student to attend PCC. If on move-in day it is not done, the student will not be able to get their rooming assignment. Thank you for your attention to this. Any questions, please contact us or your student's primary care doctor. This form is confidential and will be used only by Staff to provide care to your student. If you student will need medication at the program, HEALTH FORM #2 will be needed to filled out as well.
Student Name*

First Name/Preferred Name Last Name
Student Birthdate*

MonthDayYear
Date
FemaleMaleNon-Binary
PCC Student ID #: (This is located on student's acceptance letter)*

Has/does the participant:*

Rows	YES	NO
1. Had any recent injury, illness or infectious disease?
2. Have a chronic or recurring illness/condition?
3. Ever been hospitalized?
4. Ever had emotional difficulties?
5. Ever engaged in self-harming behaviors (i.e. cutting)?
6. Ever had an eating disorder?
7. Ever had surgery?
8. Ever had a head injury?
9. Ever been knocked unconscious?
10.Ever had seizures?
11. Ever had high blood pressure?
12. Ever been diagnosed with a heart murmur?
13. Ever had back problems?
14. Ever had problems with joints (i.e. knees, ankles)?
15. Have any skin problems (i.e. itching, rash, acne)?
16. Have diabetes?
17. Have Asthma?
18. Had mononucleosis in the past 12 months?
19. Had problems with sleepwalking?
20. Had problems with diarrhea/constipation?
21. If menstruates, have an abnormal menstrual history?
22. Had Covid-19 in the past?
23. Has your student been vaccinated against COVID-19?

Please explain any "YES" answers, nothing the number of the question (If Yes #23, please list Covid vaccine(s) and amount)
Provide any additional information about the participant's behavioral, physical, emotional or mental health about which the camp should be aware.

We keep the following medications on hand. Please indicate if we have your permission to administer these medications at the discretion of the health care provider or designee. *

Rows	YES	NO
Antihistamine (Benadryl)
Acetaminophen (Tylenol)
TUMS
Ibuprofen (Advil)
Cough Drops

If your student will require prescription medication while at PCC, you will have to fill out the following document:

PCC Health Form #2 (For Medication)

This is due by May 26th. You can turn it in by mailing it to our office or emailing it to us: pcc@stonehill.edu , you are also able to upload it here for your convenience.
If you already have Health Form #2 filled out, you can turn it in here:

Cancelof
OTHER: (List any over-the-counter medicines your child may use at PCC). Parent must provide:
Name of Physician *
Physician Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
By signing your name here, you are signing this form electronically. *

Parent/Guardian First NameParent/Guardian Last Name
Today's Date*

MonthDayYear
Date
Should be Empty: