Medical Check-In Form
A streamlined form for quick medical check-in, capturing essential health and assistance information.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Do you have any allergies?
*
Yes
No
Please list your allergies.
Do you have any hearing issues?
*
Yes
No
Please list your hearing issues.
Do you have any eyesight issues?
*
Yes
No
Please list your eyesight issues.
Do you use any mobility aids or prosthesis?
*
Yes
No
Please describe mobility aids or prosthesis.
Do you require assistance with daily living activities?
*
Shower/Bath
Eating
Toilet
Dressing
None
Other
Are you experiencing any sickness symptoms today?
*
A cough lasting longer than 2 weeks
Unexplained weight loss
Night sweats
Unexplained fevers
None
Other
Did you bring any medication with you?
*
Yes
No
List your medications.
What is your current physical condition?
*
Good
Fair
Poor
Do you have any special dietary needs?
*
Diabetic
Religious Kosher
Halaal
Vegetarian
Allergies
None
Other
Any additional camper information, history, suggestions, limitations (behavioral history, psychosocial needs and self-care needs i.e. bedwetting, sleepwalking etc).
Medical Staff Sign-Off Signature
*
Medical Staff Sign-Off Name
*
Date of Sign-Off
-
Month
-
Day
Year
Date
Photo
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit Check-In
Should be Empty: