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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