2012 Health History and Medical Form

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Insurance InformationIn order for Camp TEKO to guarantee medical services should the need arise due to illness or accident, it is

necessary to present the medical service provider with evidence of valid insurance coverage.

PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD ON A

FULL SHEET OF PAPER.

Insurance company__________________________ Name of insured______________________

Policy #___________________________________ Group #_____________________________

Employer__________________________________ Phone_______________________________

STAFF HEALTH HISTORY AND MEDICAL FORMThis form must be returned to the following address by June 1st, 2012.

Camp TEKO Forms - Temple Israel

2324 Emerson Avenue South

Minneapolis, MN 55405

Phone: 612-374-0321

The information on this form is extremely important to ensure the health and safety of all campers and staff.

Please be thorough and candid. No person will be permitted to attend camp until this form is completed.

Participant name______________________________________________________________________Last First Middle

Home address________________________________________________________________________Street address City State Zip

Gender: Male Female Birth date_______________ Age at camp_______________

Emergency contact

Name__________________________________ Relationship to Staff Member__________________

Phone (h)____________________ (w)____________________ (c)__________________________

Important

These boxes must be completed for attendance.

Health History

Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The personherein named has permission to engage in all camp activities except as noted.

I hereby give permission to the camp to provide, seek, and consent to routine health care, administration of

prescribed medications and emergency treatment for my child/me as may be necessary, including, but not

limited to x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to

arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing,

or insurance purposes.

In the event I cannot be reached in an emergency, I hereby give permission to the medical professional

selected by the camp to secure and administer treatment, including hospitalization, for the person named

above. This completed form may be photocopied for trips out of camp.

Signature of Parent/Guardian or Adult Staff Member_____________________________________________

Print name___________________________________________ Date_______________________________


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To be completed by Parent/Guardian or Adult Staff Member.

AllergiesList all known.

Medication allergies (list) Describe allergic reaction and treatment/management of the reaction.

_______________________________ ______________________________________________

_______________________________ _____________________________________________________________________________ ______________________________________________

Food allergies (list) Describe allergic reaction and treatment/management of the reaction.

_______________________________ _____________________________________________________________________________ ______________________________________________

_______________________________ ______________________________________________

Other allergies (list)include insect stings, hay fever, asthma, animal dander, etc. If the participant has an asthmatreatment plan, please attach a copy. Describe allergic reaction and treatment/management of the reaction.

_______________________________ ______________________________________________

_______________________________ ______________________________________________

_______________________________ ______________________________________________

Medications being taken

This person takes NO medications on a routine basis.Medication PolicyAll medication must be in its original container with the original label stating your name, name of medication,

doctors name and proper dosage. Medication dosage and frequency of dispensing must match the prescription

label. If there are any medication changes between the time you fill out the medical form and the first day of the

session, please notify the camp in writing. All prescription and non-prescription medication is kept in a secured

area at camp and dispensed by the camp medical professional.

_______________________ _______________ ___________________ ________________Medication Dosage Specific times taken each day Reason for taking




Health History Questions(Explain any yes answers below.)

1. Had any recent injury, illness, or infectious disease? Yes No 15. Ever been diagnosed with a heart murmur? Yes2. Have a chronic or recurring illness/condition? Yes No 16. Ever had back problems? Yes3. Ever been hospitalized? Yes No 17. Ever had problems with joints (knees, ankles)? Yes

4. Ever had surgery? Yes No 18. Have an orthodontic appliance being brought to camp? Yes

5. Have frequent headaches? Yes No 19. Have any skin problems (itching, rash, acne)? Yes6. Ever had a head injury? Yes No 20. Have asthma? Yes7. Ever been knocked unconscious? Yes No 21. Have diabetes? Yes

8. Wear glasses, contacts, or protective eye wear? Yes No 22. Had mononucleosis in the past 12 months? Yes9. Ever had frequent ear infections? Yes No 23. Had problems with diarrhea/constipation? Yes10. Ever passed out during or after exercise? Yes No 24. Have problems with sleepwalking? Yes11. Ever been dizzy during or after exercise Yes No 25. If female, have an abnormal menstrual history? Yes

12. Ever had seizures? Yes No 26. Have a history of bed-wetting?27. Ever had an eating disorder?

Yes13. Ever had chest pain during or after exercise? Yes No Yes

14. Ever had high blood pressure? Yes No 28. Ever had other emotional difficulties for whichprofessional help was sought? Yes


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The camp medical professional may administer the following over the counter medications to my child during the

course of the summer season without first contacting me/other Parent/Guardian. Please indicate by checking yes or no

which medications you will or will not permit the camp medical professional to administer.

Robitussin DM (or generic equivalent) Yes No Advil (or generic Ibuprofen) Yes No

Chloraseptic Spray Yes No Tylenol Yes No

Milk of Magnesia Yes No Sudafed Yes No

Maalox or other antacids

Yes

No Cortisone cream

Yes

NoBenadryl Yes No Caladryl Yes No

Neosporin (or generic equivalent) Yes No Solarcaine spray Yes No

Imodium Yes No

As a Parent/Guardian of this participant, I give permission to the camp medical professional to provide/dispense the

medications listed above to my child.

Signature of Parent/Guardian (if under 18) ____________________________________ Date__________

Please explain any yes answers, noting the number of the questions.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Use this space to provide any additional information about the participants behavior and physical, emotional, or mental heal th about

which the camp should be aware.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Which of the following has theparticipant had?

Please give all dates of immunization for:

Date Vacccine: Date Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/YrMeasles ____________ DTP _________ _________ _________ _________ _________ Chicken Pox ____________ TD (tetanus/diphtheria) _________ _________ _________ _________ _________ German measles ____________ Tetanus _________ _________ _________ _________ _________

Mumps ____________ Polio _________ _________ _________ _________ _________ Hepatitis A ____________ MMR _________ _________ Hepatitis B ____________ or Measles _________ _________ Hepatitis C ____________ or Mumps _________ _________

or Rubella _________ _________TB Mantoux test Haemophilius influenza B _________ _________ _________ _________Date of last test ____________ Hepatitis B _________ _________ _________Result: Positive Negative Varicella (chicken pox) _________ _________


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Physician Information

Name of participants physician____________________________ Phone______________________

Practice name___________________ Practice address______________________________________

Name of participants dentist/orthodontist____________________________ Phone______________

Practice name___________________ Practice address______________________________________

Health Care Recommendations to be completed by Licensed Medical Provider

Participant name___________________________________________________________________Last First Middle

I examined the camp participant on _____________. (Camp TEKO requires a physical exam within

24 months of camp attendance.)

BP______________ Weight______________ Height______________

The participant is under the care of a physician for the following conditions______________________

__________________________________________________________________________________

Recommendations and Restrictions at CampTreatment to be continued at camp______________________________________________________

__________________________________________________________________________________

Please review Medications being taken listed on page 2.

The medications, dosages, and schedules are appropriate. The medications, dosages, and schedules are incorrect. Comments_______________________

__________________________________________________________________________________

Any medically prescribed meal plan or dietary restrictions____________________________________

__________________________________________________________________________________

Known allergies_____________________________________________________________________

__________________________________________________________________________________

Description of any limitation or restriction on camp activities___________________________________________________________________________________________________________________

Additional information for the camp medical professional____________________________________

__________________________________________________________________________________

__________________________________________________________________________________

In my opinion, the camp participant IS IS NOT able to participate in an active camp program.

Signature of Licensed Medical Provider__________________________ Date_________________

Print name_________________________________ Phone__________________________________

This form must be returned via regular mail by May 15, 2012 to the following address:

Camp TEKO Staff FormsTemple Israel 2324 Emerson Avenue South Minneapolis, MN 55405.If you have any questions regarding this form, please contact Andrea Gordon at 612-374-0321 (Temple Israel

office). During the summer season, you can reach the Camp TEKO office at 952-471-8216.

Documents

2012 Health History and Medical Form