2025 Health Form: Child with Sickle Cell

  • Health Form: Child with Sickle Cell Disease

    Must be completed by primary hematology team or primary care doctor.

  • Who is this form for?

    This form is for any child with sickle cell between the ages of 5-15 years old who is attending Happiness Is Camping's Sickle Cell Family Camp program. 

  • Date of Exam*
     - -
  • Date of Birth*
     - -
  • Date of Diagnosis*
     - -
  • Did the Camper receive chemo?*
  • Did the Camper receive a transplant?*
  • Does the child have a Mediport, Broviac, or VP Shunt?*
  • Did the Camper receive Transfusion Therapy?*
  • Has the Camper had a splenectomy?*
  • Has the Camper ever been hospitalized because of a pain crisis?*
  • Does the Camper have a history of seizures?*
  • Varicella Status (please check all that apply)
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  • Does the Camper have diabetes?*
  • Does the Camper have asthma?*
  • Does the Camper have a history of psychiatric or behavioral issues?*
  • Are there any Over The Counter medications that should NOT be administered at Camp?*
  • Will the Camper require any treatments while at Camp?*

  • Review of Systems

  • Rows

  • Physical Examination

  • Rows

  • Licensed Medical Personnel Authorization

  • Authorization

    I have reviewed the camper/sibling health history form and have discussed the camp program with the camper's parent or guardian. It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above).

  • Format: (000) 000-0000.
  • Should be Empty: