MEDICAL HISTORY
for

_________________________________
(Campers Name)

PLEASE INDICATE IF YOUR CHILD HAS HAD ANY OF THE FOLLOWING AND
GIVE APPROXIMATE DATES OF LAST OCCURRENCE.

Frequent ear Infections _________________ Heart Condition _______________________
Hay Fever __________________________ Convulsions __________________________
Diabetes ____________________________ Asthma ______________________________
Epilepsy ____________________________ Bed Wetting __________________________
Arthritis/Joint Problems _________________ Chronic Illness ________________________
Bleeding/Clotting Disorder ______________ Seizure Disorder ______________________
Allergies _________________________________________________________________
Medical Allergies ___________________________________________________________
HAS YOUR CHILD HAD:
Chicken Pox _________________________ Measles _____________________________
Rheumatic Fever ______________________ Mumps ______________________________
Recent Surgery _______________________
PLEASE LIST ALL MEDICATIONS AND DOSAGE INSTRUCTIONS TO BE
GIVEN TO CAMPER DURING THE WEEK OF CAMP. ** PLEASE BE SURE TO
SEND MEDICATION FOR THE ENTIRE WEEK. **
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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