Doctor. Dentist. Mental Health. Other
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- Carmel Simon
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1 Page 1 Health Care Providers Specialty Name Telephone Number Doctor Dentist Orthodontist Mental Health Other May we contact your child s health care provider? Health Insurance Is your camper covered by Health Insurance? Policy Holders Name Social Security or Health Insurance ID Policy Holders D.O.B (mm/dd/yyyy) Relationship Insurance Carrier Carriers Phone # Policy# Group# RxBin# Please Provide your Insurer s Claims Processing Address Country City Address State Is your camper covered by a Prescription Plan? Plan Carrier Plan Number Additional Comments:
2 Page 2 Physical Please check all that apply. Abnormal Menstrual History Immunodeficiency Anorexia, Bulimia Joint Problems (ankles, knees) Back Problems Knocked Unconscious Bed Wetting Lice Bleeding, Clotting Mono (in the last 12 months) Chest Pain, Dizzy, Passing Out Orthodontic Appliance Required Diarrhea, Constipation Seizures, Convulsions Glasses, Contacts, or Protective Eyewear Short of Breath, Wheezing Head Injury Skin Problems (itching, rash) Heart Murmur Sleep Walking High Blood Pressure Other Issue HIV Are there any activities from which your child should be exempted or limited for health reasons? (If yes please explain) Allergies (if more than one please attach a second sheet) Does your child have any known allergies Allergy Type: Last Reaction (mm/dd/yyyy) Please describe the reaction and how it is treated: Is there a risk of an anaphylactic shock? Asthma Does your child have Asthma? If Applicable, when do they take peak flow readings? Best Range Caution Range Danger Range Are there any specific triggers that may cause a flare up? Diabetes When does your child usually take blood sugar readings? What is their Blood Sugar Range? From Minimum: to Maximum: Does your child use insulin? When was their last blood sugar reaction? (mm/yyyy) Are there any particular stressors that effect their blood sugar? Other than meals describe your child s pattern for snacks Recurring Health issues Does your child have any recurring or chronic health issues?(frequent headaches, sinus infection etc?)
3 Page 3 Has your child had any operations or serious injuries?(please describe & date each) Are there any other physical health issues a physician should be aware of? Has your child left the country in the last 9 months? (Please note date and location) Mental, Emotional and Social Health Has your child ever been diagnosed with any of the following? If yes, please answer the questions below for each If no leave clear (use additional sheet if necessary). Attention Deficit Disorder (ADD/ADHD) Depression Disordered Eating Learning or Processing Challenge Obsessive Compulsive Disorder Panic/Anxiety Disorder Substance Abuse Other My child has had none of the above Has your child received professional treatment in the past 12 months? Is your child currently taking Medication for this? Was a management regimen prepared for your child s time at camp? Please describe it below List behaviors that would indicate decompensating Has your child experienced any significant family changes? Please date and describe (e.g. Death, Divorce, Adoption, Abuse) Are you concerned about your child s ability to cope with Homesickness? YES NO Please explain
4 Nutritional Profile Page 4 Does Mabel have any Dietary Restrictions If yes please explain Medications Will your child take medications while at camp? If Yes, Medication Name: Dosage: Reason: When you bring medications to camp you will check them in with the Camp Nurse. All medications MUST be in their original containers and be accompanied by an "Authorization for Administration of Medication" form. As per the state of Connecticut regulations, without this form we will not be able to administer your child's medication. You can download the 'Authorization for administration of Medication" form from the forms dashboard or from our website under parent resources. Over the counter Medications The following medications are stocked in the Camp Sloane Health Lodge. Can your camper take the following medications? All None Acetaminophen (Tylenol) Guaifenesin (Mucinex) Acetic Acid Solution Ibuprofen (advil) (for Swimmers ear) Insect Repellant (off) Antacid (Mylanta or Tums) Loratadine (claritin products) Anti Fungal Cream/Sprays Medicane (inc. Tinactin) Medicated powder Antidiarreal (Maalox) Orasol, Ambesol and Abreva Antiseptics Pediculosis (for headlice) (alcohol, peroxide, bacitracin) Poison Ivy Treatment Benadine (contains Iodine) Pseudoehphedrine (sudafed) (pepto-bismol) Pseudoephedrine Hydrochloride Calagel and Hydrocortisone (advil cold/sinus relief) Calamine Lotion Sunscreen Bismuth Subsalicylate Visene Chamomile Tea Zyrtec Chlorpheniramine Maleate (Robitussin) Cooling Gel/Aloe Cough Drops (Generic) Diphenhydramine (Benadryl) I have carefully reviewed the over the counter medication restrictions, and confirm that the information above is correct.
5 Page 5 Diseases Tuberculosis Test Date Positive Negative Not Tested Approximate Date of Last occurance Chicken Pox Never had Chick Pox German Measles Never had German Measles Hepatitis A Never Had Hepatitis A Hepatitis B Never Had Hepatitis B Hepatitis C Never had Hepatitis C Measles Never had Measles Mumps Never had Mumps H1N1 Never had H1N1 By signing below you acknowledge and agree with the following statements. This health history is correct and complete as far as I know. The person herein named has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the Camp Director to provide routine health care; to administer medications; to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me and my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization for the person named herein. This completed form may be photocopied for trips out of camp. I authorize Camp Sloane to charge my credit card on file (or a credit card I agree to provide) for all expenses incurred by Camp Sloane for the treatment of my child. By my signature I affirm that this health history is correct and complete to the best of my knowledge and that I have read, understood and agree to the Terms and Conditions specified in this form. Name (print) Relationship to camper Signature: Date
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