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Iv medical form

Original must be mailed. Please keep a copy for your records. Completed Medical Forms must be mailed for STC by May 19 and BV by June 30, for Camp Medical Staff to review. Pages 1- 4 are to be completed by parent/guardian and reviewed by the health care provider at the time of examination. This form is used to help camp medical staff in determining appropriate care. This information will be shared on a “need to know” basis with Camp Staff. Camper Name ___________________________________________________________________________________ Home Address ________________________________________________________ Phone ____________________ Birth Date __________________ Age____________ Gender__________ Parent/Guardian Name________________________________________________ Phone __________________ Home Address ________________________________________________________ Cell ___________________ Business Address ______________________________________________________ Phone ___________________ Other Parent/Guardian Name___________________________________________ Phone ___________________ Home Address ________________________________________________________ Cell ___________________ Business Address ______________________________________________________ Phone ___________________ If parent and other parent/guardian are not available in an emergency, please notify: Name __________________________________________________________ Relationship _____________________ Address______________________________________________________________ Phone _____________________ Immunization History (Provide the month and year for each immunization. Starred (*) MUST be current. Copies from health-care providers are acceptable (please attach to this form). Diptheria, tetanus, pertussis*__________________________ Hepatitis B_________________________________ Tetanus booster* ___________________________________ Hepatitis A_________________________________ Mumps, measles, rubella*____________________________ Varicella (chicken pox) _______________________ Polio*____________________________________________ Menigococcal meningitis______________________ Haemophilus infleuzae type B _______________________ Tuberculosis (tb) test _________________________ Pneumococcal _____________________________________ 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. Signature of parent/guardian:_________________________________ Date:_________________________________ Camper’s Name ________________________ STC ________ BV________ Does the participant have family medical/hospital insurance? Yes No Carrier ______________________________________________________ Policy or Group # _________________________ Name of Policy Holder _________________________________________ Relation to Participant______________________ SS # of Policy Holder or Insurance ID Number _______________________________________________________________ IMPORTANT— PLEASE READ CAREFULLY AND SIGN Parent or Guardian Consent: This health history is correct and complete to my knowledge. The person de-scribed has permission to participate in all camp activities except as noted. I give permission to photocopy this form. I hereby give permission to the camp to obtain relevant health care, administer prescribed medications, and seek emergency medical treatment, including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission for the camp to arrange related transportation for my child. The purpose of onsite camp medical staff is solely for administering medications and performing tri-age and minor first-aid. In the event that I cannot be reached in an emergency, I hereby give permission to the health care provider selected by the camp to secure and administer treatment, including hospitalization. Parents/guardians are responsible for ALL medical bills incurred while at camp (doctor visits, emergency room visits, and prescriptions). All attempts will be made to contact parent/guardian before taking the camper for “off camp medical care.” A description of care received will be given to the parent. Signature of Custodial Parent/Guardian: ___________________________________________________________ Witness: _____________________________________________ Date: _____________________________________ Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD) Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder? Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns? Yes No 4. Had a significant life event that continues to affect the camper’s life? Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Camper’s Name ________________________ STC ________ BV________ GENERAL HEALTH HISTORY Participant has or has had any of the following: (Please check if YES.) Please explain any “yes” answers: _________________________________________________________________________________________________ _________________________________________________________________________________________________ IF FEMALE (Please answer YES or NO.) Has this person menstruated? ____ If not, has she been told about it? ____ Is her menstrual history normal? ____ ALLERGIES (list all known) Describe the reaction and management of the reaction. Medication Allergies (list) ___________________________________________________________________________ _________________________________________________________________________________________________ Food Allergies (list) - (i.e. Nuts, lactose intolerance, shellfish, etc.____________________________________________ _________________________________________________________________________________________________ Other Allergies (list) - (i.e. insect stings, hay fever, asthma, animal, plant, etc.) _________________________________________________________________________________________________ RECOMENDATIONS AND RESTRICTIONS Explain what limitations are necessary. no restriction restriction:_________________________________________________ no restriction restriction:_________________________________________________ no restriction restriction:__________________________________________________ (Is capable of swimming the deep end of the pool?) yes no uncertain (Certified lifeguard will evaluate.) Other restrictions: ________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Camper’s Name ________________________ STC ________ BV________ MEDICATIONS BEING TAKEN Please list all prescription and non-prescription medications taken on a regular ba-sis. Please keep in original bottles labeled with health care provider’s name, phone number, dosage and instructions. Place all medicines in one plastic Ziploc bag and label with camper’s name. Note: It is camp policy that all medications will be kept and secured at the Camp Infirmary. This includes vitamins/supplements and medications taken on an “as needed basis.” The only medicines that may be left in cabins are creams and inhalers. Please attach additional pages for more medications. Make sure to notify the medical staff when you arrive at camp if additional medications have been added after the health form was filled out. 1) Med ______________________ Dosage ____________________ Specific times per day _____________________ Reason for taking _______________________________________________________________________________ 2) Med ______________________ Dosage ____________________ Specific times per day _____________________ Reason for taking _______________________________________________________________________________ 3) Med ______________________ Dosage ____________________ Specific times per day _____________________ Reason for taking _______________________________________________________________________________ The following non-prescription medications may be given to my child, if needed: (Please circle YES or NO) Cough syrup, lozenges, throat spray YES NO External ointments, sprays. lotions YES TO BE COMPLETED BY LICENSED HEALTH CARE PROVIDER I examined this individual on ____________________ (Exam must be performed within 12 months of camp attendance.) BP _______________ Weight _______________ Height _______________ I have personally reviewed the above health information and activity restrictions and have made any necessary corrections or additions. Signature of Licensed Health Care Provider ______________________________________________________ Name (printed) ______________________________________________ Title _______________________________ Address _________________________________________________________________________________________ Phone _________________________________________ Date __________________________________________ Meds received ___________________________________________________________________________________ ________________________________________________________________________________________________ Current health needs identified _____________________________________________________________________ Observational notes ______________________________________________________________________________ Screened by _____________________________________ Date __________________________________________

Source: http://www.ionianvillage.org/assets/files/forms/IV%20Medical%20Form.pdf

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