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Mayhew Program Staff Health History and Examination Form
• According to NH State Law, you must provide “a health history and statement of health status as prepared by a physician, doctor of osteopathy, advanced registered nurse practitioner, or a physician’s assistant prior to attending a Youth Recreation Camp. The statement shall include a certification that the physical examination has been completed within 2 years prior to YRC entrance.”
• You may use this form or substitute one as provided by your doctor. Name: ____________________________________________________________ DOB: ______/_____/___________ Mailing Address: ________________________________________________________State:_______ZIP:_____________ If different from Mailing Address. Physical Address: _______________________________________________________State:_______ZIP:_____________ IN AN EMERGENCY, CONTACT
Emergency Contact:__________________________________________________ Relationship:____________________ Mailing Address: ________________________________________________________State:_______ZIP:______________ If different from Mailing Address. Physical Address: _______________________________________________________State:_______ZIP:______________ Are you covered by medical/hospital insurance? □Yes □No If so, indicate carrier or plan name:____________________________________ Policy # __________________________________ 3. Read and Sign Authorization for Health Care: This health history is correct and accurately reflects my health status. In the event that I become incapacitated, I give my
permission to the physician selected by the Mayhew Program to hospitalize, secure proper treatment for, and order injection,
anesthesia, or surgery for me. 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.
Signature ________________________________________________________________ Date: _____/____/__________
Printed Name:____________________________________________________________________ Type of Allergy
Type of Reaction (rash, swelling, vomiting, etc.)
Please make note of any medications you take on a regular basis. You may skip this section, but please be aware that in the event of a medical emergency, the information in this form with be shared with the medical practitioner The following non-prescription medications may be stocked in the camp Infirmary and are used on an as needed basis to manage illness and
injury. CROSS OUT THOSE YOU SHOULD NOT BE GIVEN.
Acetaminophen (Tylenol)
Phenylephedrine decongestant (Sudafed PE) Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Complete the fol owing or attach a separate record of your immunization history Check “Yes” or “No” for each statement. Explain “Yes” answers below.
1. Ever been hospitalized? ……………………………….…. □ Yes □ No 10. Had fainting or dizziness? …………………………….…. □ Yes □ No 2. Ever had surgery? ……………………………………….…… □ Yes □ No 11. Wear glasses or contacts? …………………………….…. 3. Have recurrent/chronic il nesses? ………………….……. □ Yes □ No 12. Passed out during exercise? ………………………….…. 4. Had a recent infectious disease? ……………………. □ Yes □ No 13. Had mononucleosis during last 12 months? ………. 5. Had a recent injury? ………………………………………. □ Yes □ No 14. Have problems with falling asleep/sleepwalking? …. Yes □ No 6. Had asthma/wheezing? ……………………………………. □ Yes □ No 15. Ever had back/joint problems? …………………………. Yes □ No 7. Have diabetes? ………………………………………………. □ Yes □ No 16. Have a history of bedwetting? .……………………. 8. Had seizures? ………………………………………………. □ Yes □ No 17. Have problems with constipation/diarrhea? …….…. Yes □ No 9. Had headaches? ………….……………….…………….…… □ Yes □ No 18. Have any skin problems? ……………………………….… Please explain “yes” answers here, noting the number of the questions. 8. Is there anything else we should know? What have we forgotten to ask? Please provide in the space below any additional information about your health that you think important or that may affect your ability to fully participate in Mayhew’s summer program. Family Physician: __________________________________________________ Phone:__________________________ Address: __________________________________________________________________________________________ Family Dentist: ____________________________________________________ Phone:__________________________ Address: __________________________________________________________________________________________ 9. Provide proof of a recent physical exam: ATTENTION MEDICAL PRACTITIONER
• You may attach a copy of a completed physical exam that is less than two years old and signed by a medical practitioner. • Otherwise, • Review this form in its entirety (pages 1-4) for accuracy • Complete the following physical exam details • Attest to the participant’s readiness to participate in camp activities • Sign and date. Physical Exam and Statement of Readiness for Camp Activities
Date of most recent physical exam: ____/____/________ Height: ________ft ________in Weight: __________________lbs Blood Pressure: __________/___________ Allergies: □ No Known Allergies
□ I have reviewed/revised the ALLERGIES section on PAGE 2 of this form
Medications:
□ I have reviewed/revised the MEDICATIONS section on PAGE 2 of this form
Do you feel this person will require limitations or restrictions to activity while at camp? □ No □ Yes If you answered “yes” , what do you recommend? (describe below—attach additional information if needed)
“It is my opinion that this person is physically and emotionally fit to participate as a staff
member in an active camp program (except as noted above).” □ Yes □ No
Name of licensed practitioner (please print):________________________________________Title: ___________________ Signature:___________________________________________________________________ Date: __________________ Office Address:_______________________________________________ Telephone: (______)________-_____________

Source: http://www.mayhew.org/downloads/staffhealthform.pdf