Form C-MossRehab Camp Independence 2017-Medical Information

Transcription

1 Form C-MossRehab Camp Independence 2017-Medical Information DIRECTIONS FOR COMPLETION: Step 1. This form must be fully completed and signed by the applicant s physician. No substitutions of this form will be accepted. All applicants must have a medical examination within twelve months prior to the start date of MossRehab Camp Independence which is June 18, In order to be considered for admission to MossRehab Camp Independence, this form must be fully completed and received by MossRehab no later than Monday, March 20, 2017 for returning campers and no later than Monday, March 27, 2017 for potential campers. No exceptions can be granted. Step 2. Mail To: MossRehab at Elkins Park Attention: Recreation Therapy Department/Camp Independence 60 Township Line Road Elkins Park, PA OR Fax To: Attention: Recreation Therapy Department/Camp Independence PLEASE PRINT Applicant s Information Applicant s Name Date of Examination / / Disability or diagonosis Date of Birth Age Gender: Male or Female Height Weight Blood Pressure Pulse 1

2 Immunizations History Are applicant s vaccinations immunizations on schedule / up-to-date? Yes No Tetanus: Date of last booster: * All applicants must have had a tetanus booster within the last 10 years to attend camp.* PPD: Date of last test: Positive or Negative If positive PPD, date of last chest x-ray: Positive or Negative Shunt History Does applicant have a shunt? Yes No If yes, date of last shunt revision: Seizures Does applicant have seizures? Yes No Under control with medication? Yes No What type of seizure? Duration of seizure? Date of last seizure? How many seizures in the last six months? _ Known precipitating factors (triggers): _ Describe behavior before seizure: Describe behavior during seizure: Describe behavior after seizure: Describe protocol normally followed: Please note: Applicant must be on a stable medication regime and NOT be in the process of changing medication or altering the dosage of current medication for at least one month prior to camp. 2

3 Allergies /Diet No Latex Allergy Yes Latex Allergy (MossRehab Camp Independence strives to be a latex free environment.) No Medication Allergies Yes Medication Allergies If yes, list all medication allergies. Please be specific: No Food Allergies Yes Food Allergies If yes, list all food allergies. Please be specific: No Swallowing Issues Yes Swallowing Issues If yes, please explain: No Dietary Modification Needed Yes Dietary Modification Needed If yes, list all dietary modification needed (puree food, thick liquids). Please be specific: 3

4 Medications List all medications currently used by applicant. If additional space is needed, please photocopy this part of the health form. Inhalers and EpiPen information must be included, even if they are for occasional or emergency use only. 4

5 Speech Normal Mildly Affected Moderately Affected Severely Affected Few Words Non-Verbal If applicant has partial or total loss of hearing, please explain the best way to communicate with him/her: _ Communication Can applicant communicate wants/needs? Yes No Is applicant able to communicate pain? Yes No Does applicant understand and respond to yes/no questions? Yes No Method(s) of communication: Verbal Sign Language Communication Board Communication Device Points Grunts Gestures ipad Writing Other: Further communication instructions and assistance required: _ Travel Has the applicant traveled outside the country in the past 9 months? Yes No If yes explain below. Please name countries visited and dates of travel: _ 5

6 Health History Eye/Vision Problems Yes No Requires glasses/contacts/protective eyewear Ear/Hearing Problems Yes No Requires hearing aides General / Precautions M.R.S.A. / V.R.E. Yes No Hepatitis Yes No Recent Infectious Disease Yes No Recent Injury Yes No Recurrent/Chronic Illness Yes No Blood Disorder Yes No Anemia Yes No Blood Clots Yes No Skin Problems Yes No Pressure Ulcers/Wounds Yes No Cancer Yes No Lyme Disease Yes No Lupus Yes No Edema Yes No Respiratory Health Asthma/Breathing Problems Yes No Sinusitis/Bronchitis/Pneumonia Yes No C.O.P.D. Yes No Sleep Apnea Yes No Cardiovascular Health Artery/Vascular Disease Yes No Congenital Heart Disease Yes No Congestive Heart Failure Yes No Heart Attack Yes No Chest Pain Yes No Cardiac Arrhythmia Yes No High Blood Pressure Yes No Elevated Cholesterol Yes No Implantable Devices Yes No Chest pain / Fainting with physical activity Yes No Endocrine Health Diabetes Yes No Hypoglycemia / Hyperglycemia (circle) Insulin Dependent Yes No Osteoporosis / Osteopenia Yes No Thyroid Problems Yes No 6

7 Neurological Health Cerebral Palsy Yes No Charcot-Marie-Tooth Disease Yes No Muscular Dystrophy Yes No Traumatic/Brain Injury Yes No Chiari Malformation Yes No Hydrocephalus Yes No Migraines/Frequent Headaches Yes No Fainting/Dizziness Yes No Stroke/TIA Yes No Hemiplegia/ Hemiparesis Yes No Spina Bifida Yes No Spinal Cord Injury Yes No Paraplegia Yes No Quadriplegia Yes No Multiple Sclerosis Yes No Parkinson s Disease Yes No ALS/ Lou Gehrig's Disease Yes No Fibromyalgia Yes No Neuropathy Yes No Musculoskeletal Health Back / Neck / Joint Problems Yes No Arthritis Yes No Osteoarthritis / Rheumatoid Arthritis (circle) Gout Yes No Degenerative Joint Disease Yes No Scoliosis Yes No Joint Replacement Yes No Amputation Yes No Fractures Yes No Gastrointestinal Health Frequent Nausea/Vomiting Yes No Acid Reflux (G.E.R.D.) Yes No Stomach Problems Yes No Gall Bladder Problems Yes No Irritable Bowel Syndrome Yes No Diarrhea Yes No Constipation Yes No Incontinence of Bowel Yes No Genitourinary Health Kidney Problems Yes No Bladder Problems Yes No Frequent Urinary Tract Infections Yes No Incontinence of Urine Yes No Intermittent incontinence Yes No (i.e., night-time) Female Applicant: Menstrual Problems Yes No Vaginal Infections Yes No Date of last menstrual period: 7

8 Hospitalizations / Surgical History Surgical Procedures Month/Year Surgical Procedures Month/Year Most Recent Hospitalization(s): Date(s): Reason(s): Psychological / Emotional / Social / Behavioral Health Psychiatric Condition(s) Yes No Depression Yes No Anxiety Yes No Eating Disorder Yes No Sleep Disorders Yes No Problems falling asleep Yes No Sleepwalking Yes No Has the applicant: 1. Ever been treated for emotional or behavioral difficulties? Yes No 2. In the past 12 months, seen a professional to address mental/emotional/behavioral health concerns? Yes No 3. Had a significant life event that continues to impact the applicant s daily life? (History of abuse, death of a loved one, family changes, survived a tragedy, other) Yes No Please explain yes answers in the space below, referencing the question number in your response. The camp administrator may contact you for additional information. _ 8

9 Restrictions Activity Restriction(s) (swimming, etc.). Please list: _ Dietary Restriction(s) (sugar, caffeine etc.). Please list: 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. Medication will be given as directed on the label, unless otherwise instructed by physician. Cross out those the applicant should NOT be given. Acetaminophen (Tylenol) Antihistamine/Allergy Medicine (Benadryl) Ibuprofen (Advil, Motrin) Calamine Lotion Phenylephrine Decongestant (Sudafed PE) Antibiotic Cream Pseudoephedrine Decongestant (Sudafed) Aloe Cough syrup (Robitussin) Laxatives for Constipation (Ex-Lax) Sore Throat Spray Generic Cough Drops Bismuth Subsalicylate for Diarrhea (Kaopectate, Pepto- Bismol) I have examined the above name applicant and have reviewed their health history. In my opinion this applicant is capable of physically engaging in MossRehab Camp Independence except for the restriction (s) noted above. Physician s Name (please print) Physician s Phone Number: Physician s Address: City: State: ZIP: Physician Signature: Date: Physician s License Number: State: 9