MEDICAL FORM (To be completed by Physician) Student’s Name ____________________________________________ Address: __________________________________________________ Date of Birth (mo/day/yr)_________________ M / F (Please circle one) MEDICAL HISTORY Please indicate the childhood illnesses the student has had and complete the information about student’s current physical condition. If the student has not had that illness or condition, please check the “NO” box. CHILDHOOD ILLNESSES Chicken Pox German Measles Measles Mumps Shingles ALLERGIES Hay Fever Insect Sting Reaction Penicillin Poison Ivy, Poison Oak, etc. Yes No Date CURRENT PHYSICAL CONDITIONS Asthma Bleeding/Clotting Disorder Cancer Convulsions/Seizures Diabetes Frequent Ear Infections Heart Defect/Disease High Blood Pressure Kidney Disease Lung Disease Vision Impairment Yes No IMMUNIZATION HISTORY The New York State Department of Health requires a complete immunization history for each student enrolled in the EYF program. This information must be completed by the student’s physician or nurse practitioner. We also ask that the EYF Program Coordinator be notified if the student has been exposed to any communicable diseases in the three weeks prior to the start of the program. The student cannot be enrolled until we have this information on file. st
nd
rd
DPT (Diphteria, 1 2 3 Pertussis & Tetanus) List dates received st
nd
rd
Polio (Oral) 1 2 3 List dates received st
nd
MMR (Measles, 1 2 Mumps, Rubella) List dates received st
nd
rd
Varicella (chicken pox) 1 2 3 List dates received st
nd
rd
HIB (Hemophilus 1 2 3 Influenza Type B) List dates received st
nd
rd
HB (Hepatitis B) 1 2 3 List dates received I verify that all immunizations are current for the above named student. Booster Booster Booster Booster Booster Booster Booster TB Test Given? YES NO Date Name of Doctor or Nurse Practitioner: ____________________________________________________________________________ Doctor’s Address: ____________________________________________________________________________________________ Phone Number: ______________________________________________________________________________________________ Doctor’s Signature: _____________________________________________________ Date: _________________________________ Page 1 of 2 6-‐DAY MEDICATION RECORD SESSION 1: July 11 – 16, 2015 SESSION 2: July 18 – 23, 2015 Name: ______________________________________________ Date of Birth: ______________________ (mo/day/year) IT IS EYF PROGRAM POLICY THAT, AT CHECK IN, ALL MEDICATIONS MUST BE GIVEN TO EYF HEALTH STAFF TO BE KEPT IN A SECURE PLACE MONITORED BY EYF HEALTH STAFF OR TEAM LEADERS. MEDICATION NAME MEDICAL CONDITION DOSE START DATE END DATE TIME (am/pm) or with Meal ** If you need more space, please attach additional page. This form is confidential and will be shredded by August 15, 2015. ** ***** All medications must be in their original vial which outlines the prescription and ***** the doctor’s contact information. OVER-‐THE-‐COUNTER MEDICATIONS AVAILABLE AT EYF FOR CAMPERS WITH PERMISSION The following over-‐the-‐counter medications are available from EYF Health staff. Please indicate if the student has permission to take each of these medicines “as needed” by checking yes or no. Only medicines that are circled “YES” and determined to be necessary will be administered at the discretion of a registered nurse. Administration of these medicines will be per label instructions unless otherwise indicated by the student’s physician. Please circle “YES” or “NO” for each medication: Tylenol (discomfort/fever) Advil (discomfort/fever) Throat Lozenges (throat irritation/cough) Benadryl or Claritin (allergies) Chloraseptic Spray (throat irritation) Cortizone Cream (topical for skin irritation) Visine (regular and allergy for eye irritation) Milk of Magnesia (constipation) YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO Imodium (diarrhea) Mylanta (stomach upset) Tums (heartburn/stomach upset) Auro Dri (swimmer’s ear) Hydrogen Peroxide Neosporin Pepto Bismol YES YES YES YES YES YES YES NO NO NO NO NO NO NO Comments:________________________________________________________________________________________________ __________________________________________________________________________________________________________ Campers are responsible for informing EYF Staff that they need to take their “as needed” medication. Campers may not share any medication with other campers and may not sell their medication to other campers. Parent/Guardian name (please print): ___________________________________________________________________________ Parent/Guardian signature: ___________________________________________________ Date: ___________________________ Doctor’s signature: __________________________________________________________ Date: ___________________________ Page 2 of 2