TREFOIL ACADEMY, LLC CAMPER HEALTH HISTORY FORM PART 1

TREFOIL ACADEMY, LLC CAMPER HEALTH HISTORY FORM PART 1

Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses.
To Parent(s)/Guardian(s): If additional information needs to be provided, please contact trefoilacademy@gmail.com
Dates will attend camp: from*

MonthDayYear
Date
to*

MonthDayYear
Date
Camper Name:*

First NameMiddle InitialLast Name
Gender Identity*

FemaleGender FluidGender NeutralMaleOther
Birth Date*

MonthDayYear
Date
Age on arrival at camp:*
Contact Information
Camper Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/guardian with legal custody to be contacted in case of illness or injury:*

First NameLast Name
Relationship to Camper:*
Preferred Phone:*
Email:*
example@example.com
Home Address: (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second parent/guardian or other emergency contact:*

First NameLast Name
Relationship to Camper:*
Preferred Phones:*
Email:*
example@example.com
Allergies:
This camper is:*

Has NO AllergiesFoodMedicineThe environment (insect stings, hay fever, etc.)Other
(Please describe below what the camper is allergic to AND the reaction and its severity that is seen.)
Diet & Nutrition:
This camper:*

Eats a regular diet.Eats a regular vegetarian diet.Is lactose intolerant.Is gluten intolerant.Other
Restrictions:
Restrictions*

I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)
Please describe the restrictions or adaptations needed.
Medical Insurance Information:
This camper is covered by family medical/hospital insurance*

YesNo
Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company*
Policy Number*
Subscriber*
Insurance Company Phone Number*
File Upload

Cancelof
Immunization History
Is your camper:*

Fully immunized. I will be entering their dates into the online table in this form.Fully immunized or will be. I will be sending a copy of their record later via the immunization record and proof of recent physical collection survey located on the Adventurer's Compendium. (Copies of immunization forms from health-care providers or state or local government are acceptable.)Is ***NOT*** fully immunized.
Immunization History: Provide the month and year for each immunization. Starred (*) immunizations must include date to meet ACA Standard.

If the camper had the chicken pox, when did they have it:*

MonthDayYear
Date
Tuberculosis (TB) test date:*

MonthDayYear
Date
Tuberculosis (TB) test result*

NegativePositive
Is your camper missing any of the following immunizations?*

TDap 1Hepatitis AHepatitis BMMRPolioOther
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.*

Clear
Guardian's Signature
Date:*

MonthDayYear
Date
Medications

"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Medication Administration*

This camper will NOT be taking medications while attending campThis camper WILL be taking the following medication(s) at camp.
For each medication, please complete a new row.*
Non-Prescription Medications

The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.

Generic variations may be purchased rather than the brand names. If the brand is listed, it is an example of that medication.
I am:*

granting permission for the following medications to be administered.NOT granting permission for any over-the-counter medications to be administered in the event of illness or injury.
Please select all medications you are approving. Each selected medication will be given only as needed.*

Acetaminophen (Tylenol)Phenylephrine decongestant (Sudafed PE)Antihistamine/allergy medicineDiphenhydramine antihistamine/allergy medicine (Benadryl for example)Antihistamine (Benadryl for example) creamSteroid/hydrocortisone creamSore throat sprayLice shampoo or cream (Nix or Elimite for example)Calamine lotion For ExampleLaxatives for constipation (Miralax for example)Ibuprofen (Advil, Motrin for example)Pseudoephedrine decongestant (Sudafed for example)Guaifenesin cough syrup (Robitussin for example)Dextromethorphan cough syrup (Robitussin DM for example)Generic cough dropsAntibiotic creamAloeBismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol for example)Children's pepto/antacidTums/antacid tab
General Health History:

Please answer each question.*

	Never	Past month	Past 3 months	Past 6 months	Past Year	Lifetime
1. Been Hospitalized
2. Had surgery
3. Recurrent/chronic illness
4. Infectious Disease
5. Injury
6. Asthma/wheezing/shortness of breath
7. Diabetes
8. Seizures
9. Severe Headaches
10. Glasses/contacts/protective eye wear
11. Fainting or dizziness
12. Passed out during exercise
13. Chest pain during exercise
14. Mononucleosis (mono)
15. Problems with periods/menstruation
16. Problems falling asleep
17. Sleepwalking
18. Back pain
19. Joint pain
20. Bedwetting
21. Diarrhea
22. Constipation
23. Skin problems
24. Traveled outside of the country

Please explain "Not - Never" answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. If all above answers are "never", please put "n/a" *
Mental, Emotional, and Social Health:

Check "Yes" or "No" for each statement. Explain "Yes" answers below.*

	Never	Past month	Past 3 months	Past 6 months	Past Year	Lifetime
1. Attempted to runaway or runaway.
2. Attempted to commit suicide or expressed suicide ideation
3. Battled an eating disorder or has been suspected of having an eating disorder
4. Sleep walked or has been suspected of sleep walking.
5. Seen a professional to address mental/emotional health concerns?
6. Ever been treated for emotional or behavioral difficulties?
7. Ever battled an eating disorder?
8. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
9. Had a significant life event that continues to affect the camper's life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)

Please explain all "not never" answers in the space below, noting the question's #. Please feel free to attach pages. You may be contacted for additional information depending on the question and recent nature. If all answers are "never", please put "n/a".
Health-Care Providers:
(Please check all that apply) My camper:*

has a primary doctorhas a dentisthas a orthodontistdoes not have any of the above.
Name of camper's primary doctor(s):*
Phone of camper's primary doctor(s)::*
Name of dentist(s):*
Phone of dentist(s)::*
Name of orthodontist(s):*
Phone of orthodontist(s)::*
Additional Notes
What Have We Forgotten to Ask?
Please provide in the space below any additional information about the camper's health that you think important or that may affect the camper's ability to fully participate in the camp program.
Parent/Guardian Authorization for Health Care:
* This health history is correct and accurately reflects the health status of the camper to whom it pertains. If the information enclosed requires updating, I will contact the camp no later than one month before camp or as soon as possible in the event of a medical issue that occurs in the final month before camp.

* The person described has permission to participate in all camp activities except as noted by me and/or an examining physician.

* I give permission to the physician selected by the camp to order x-rays, routine
tests, and treatment related to the health of my child for both routine health care and in emergency situations.

* If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child.

* I understand the information. on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.
Signature of the Custodial Parent/Guardian*

Clear
Date:*

MonthDayYear
Date
Relationship to Camper:*
Should be Empty:

	Dose 1 Month/Yr	Dose 2 Month/Yr	Dose 3 Month/Yr	Dose 4 Month/Yr	Does 5 Month/Yr	Most Recent Month/Yr
Diptheria, tetanus, pertussis (DTaP) or (TdaP)
Tetanus booster * (dt) or (TdaP)
Mumps, measles, rubella (MMR)
Polio (IPV)
Haemophilus influenzae type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (Chicken Pox)

TREFOIL ACADEMY, LLC CAMPER HEALTH HISTORY FORM PART 1

Contact Information

Allergies:

Diet & Nutrition:

Restrictions:

Medical Insurance Information:

Immunization History

Medications

General Health History:

Mental, Emotional, and Social Health:

Health-Care Providers:

Additional Notes

Parent/Guardian Authorization for Health Care: