1. health and fitness
2. disease
3. allergies

Health History
Page 1
Health Care Providers
Specialty
Name
Telephone Number
Doctor
______________________________
________________________
Dentist
______________________________
________________________
Orthodontist
______________________________
_______________________
Mental Health
______________________________
________________________
Other
______________________________
________________________
May we contact your child’s health care provider?
YES ☐ NO ☐ Health Insurance
Is your camper covered by Health Insurance?
YES ☐
NO ☐
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?
YES ☐
NO ☐ Plan Carrier ___________________________________________________________________
Plan Number__________________________________________________________________
Additional Comments: Health History
Physical Health History
Please check all that apply.
☐ Abnormal Menstrual History
☐ Anorexia, Bulimia
☐ Back Problems
☐ Bed Wetting
☐ Bleeding, Clotting
☐ Chest Pain, Dizzy, Passing Out
☐ Diarrhea, Constipation
☐ Glasses, Contacts, or Protective Eyewear
☐ Head Injury
☐ Heart Murmur
☐ High Blood Pressure
☐ HIV
Page 2
☐ Immunodeficiency
☐Joint Problems (ankles, knees)
☐ Knocked Unconscious
☐ Lice
☐ Mono (in the last 12 months)
☐ Orthodontic Appliance Required
☐
Seizures, Convulsions
☐ Short of Breath, Wheezing
☐
Skin Problems (itching, rash)
☐Sleep Walking
☐
Other Issue
Are there any activities from which your child should be exempted or limited for health reasons? YES ☐
NO ☐ (If yes please explain) Allergies (if more than one please attach a second sheet)
Does your child have any known allergies
YES ☐
NO ☐ Allergy Type:____________________________
Last Reaction (mm/dd/yyyy)_______________
Please describe the reaction and how it is treated: __________________________________
__________________________________________________________________________
Is there a risk of an anaphylactic shock?
YES ☐
NO ☐ Asthma
Does your child have Asthma?
YES ☐
NO ☐ 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
YES ☐
NO ☐ When does your child usually take blood sugar readings? ___________________________________
What is their Blood Sugar Range? From Minimum:________________ to Maximum:______________
Does your child use insulin?
YES ☐
NO ☐ 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?)
_________________________________________________________________________________
__________________________________________________________________________
Health History
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? YES ☐
NO ☐ Is your child currently taking Medication for this? YES ☐
NO ☐ 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? YES ☐
NO ☐ 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_____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Health History
Page 4
Nutritional Profile
Does Mabel have any Dietary Restrictions
YES ☐
NO ☐ If yes please
explain__________________________________________________________________________________ ______________________________________________________________________________________________________
______________________________________________________________________________________________________
Medications
Will your child take medications while at camp?
YES ☐
If Yes, Medication Name:________________ Dosage: ___________
Reason:___________________
NO ☐
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)
Acetic Acid Solution
(for Swimmers ear)
Antacid (Mylanta or Tums)
Anti Fungal Cream/Sprays
(inc. Tinactin)
Antidiarreal (Maalox)
Antiseptics
(alcohol, peroxide, bacitracin)
Benadine (contains Iodine)
(pepto-bismol)
Calagel and Hydrocortisone
Calamine Lotion
Bismuth Subsalicylate
Chamomile Tea
Chlorpheniramine Maleate
(Robitussin)
Cooling Gel/Aloe
Cough Drops (Generic)
Diphenhydramine (Benadryl)
☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES
YES
YES
YES
YES
☐
☐
☐
☐
☐
NO
NO
NO
NO
NO
☐
☐
☐
☐
☐
Guaifenesin (Mucinex)
Ibuprofen (advil)
Insect Repellant (off)
Loratadine (claritin products)
Medicane
Medicated powder
Orasol, Ambesol and Abreva
Pediculosis (for headlice)
Poison Ivy Treatment
Pseudoehphedrine (sudafed)
Pseudoephedrine Hydrochloride
(advil cold/sinus relief)
Sunscreen
Visene
Zyrtec
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
YES ☐
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
YES ☐ NO ☐
I have carefully reviewed the over the counter medication restrictions, and confirm that the
information above is correct.
Health History
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
____________________
Hepatitis C
____________________
Measles
____________________
Mumps
____________________
H1N1
____________________
☐
☐
Never Had Hepatitis B ☐
Never had Hepatitis C ☐
Never had Measles ☐
Never had Mumps ☐
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________________